Transcript Findings from the National Treatment Center Study

Workforce Retention
in Addiction Treatment:
Findings from the
National Treatment Center Study
Paul M. Roman, Principal Investigator
Co-Investigators: Aaron Johnson, Hannah K.
Knudsen, and Lori J. Ducharme
This research is supported by NIDA Research Grants
R01DA13110, R01DA14482, & R01DA14976
The University of Georgia
Goals of This Session
• To briefly outline the research design of the
National Treatment Center Study
• To describe the addiction workforce, including
counselors and program leaders
• To present data and information on counselor
turnover at the organizational-level
• To discuss burnout and turnover intention
among program leaders
• To outline how programs may reduce
counselor burnout and turnover intention
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The National Treatment Center Study:
An Overview
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Key Goals of the NTCS
• To document the range of treatment
services available in the American
substance abuse treatment system
– Levels of care, use of medications, types of
therapies, wraparound services
• To understand issues related to
workforce retention, including both
counselors and program leaders
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Types of Treatment Organizations
in the NTCS
• This presentation focuses on:
–
–
–
–
Publicly funded programs
Privately funded programs
Therapeutic communities (TCs)
Centers affiliated with NIDA’s Clinical Trials
Network
• Recently we added methadone programs, but
data are not yet available for analysis
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Public Centers
• Nationally representative sample of 362
public centers
– 80% response rate
• Eligibility for study defined by funding
sources:
– > 50% of revenues from government
grants/contracts
– Includes government-owned facilities and nonprofit programs that rely on public funding
– Average center receives 84% of its funding from
public sources
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Private Centers
• Nationally representative sample of 403
private centers
– 88% response rate
• Eligibility for study defined by funding
sources:
– < 50% of revenues from government
grants/contracts
– Includes for-profit facilities and non-profit
programs that rely on private funding (e.g.
insurance, self-paying clients)
– Average center receives less than 20% of its
funding from public sources
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Therapeutic Communities
• Nationally representative sample of 380 TCs
– 83% response rate
• Programs only required to identify themselves
as TCs
– Captures the spectrum of programs that report
using this treatment model
– Interviews include measures such as De Leon’s
“Essential Elements” and membership in
Therapeutic Communities of America to see how
closely programs adhere to the classic TC models
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NIDA’s Clinical Trials Network
• The CTN is a research network that links
university-based researchers with communitybased treatment programs in order to:
– Conduct multi-site clinical trials of treatment
techniques
– Improve addiction treatment quality by moving
evidence-based techniques into practice
• 240 CTN-affiliated treatment programs
participated in the NTCS
– 92% response rate
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Types of Programs NOT in the NTCS
•
•
•
•
•
Programs based in correctional settings
VA programs
Halfway houses & transitional housing
DUI services
Counselors in private practice
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Basic Research Methods
• Data collected from mid-2002 to early 2004
• Three levels of data collection
– Organizations
 Face-to-face interviews with administrators & clinical directors
 Organizational structure, availability of services, staffing
– Leaders
 Mailback questionnaire
 Leadership style, organizational strategy, burnout, turnover
intention, demographic characteristics
– Counselors
 Mailback questionnaire
 Job characteristics, attitudes toward innovations, burnout,
turnover intention, demographic characteristics
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The Addiction Workforce:
Characteristics of Leaders
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Average Leader Age & Tenure
• The average leader is about 50 years old
– Private center average = 49.9 years
– Public center average = 49.7 years
 In a recent survey of American full-time workers, the average age of
managers was 42.6 years
• The average leader has worked for their center for nearly 10
years
– Private center average = 9.4 years
– Public center average = 9.4 years
 In a recent survey of American full-time workers, the average manager
had worked for their organization for 10.9 years
• On average, leaders have worked 18-19 years in the behavioral
health field
– Private center average = 19.5 years
– Public center average = 18.8 years
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Leader Characteristics:
Gender
100%
75%
50%
25%
0%
45.7%
47.2%
% Female
Public
Private
• Nearly half of program leaders are female.
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Leader Characteristics:
Racial/Ethnic Minorities
100%
75%
50%
25%
0%
22.4%
8.5%
% Minorities
Public
Private
• Public centers are more likely than private
centers to have a leader with minority
background.
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Leader Characteristics:
Educational Attainment
100%
75%
50%
25%
0%
64.1%
69.6%
% MA Degree or Higher
Public
Private
• The majority of leaders have at least a
Master’s-level degree.
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Leader Characteristics:
Personal Recovery Status
100%
75%
50%
25%
0%
35.5%
38.0%
% Recovering
Public
Private
• About one-third of leaders are personally in
recovery from substance abuse.
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Average Leader Salary
• The average leader earns between
$55,000 and $65,000 per year
• Leaders of private centers earn more
($64,496) than leaders of public centers
($56,010)
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Workforce Retention “At the Top”:
Turnover Intention
and Emotional Exhaustion
Among Program Leaders
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Turnover in the Context of
Leadership
• There has been growing concern about high
rates of turnover among counselors at
treatment programs
• Relatively little is known about turnover
among program leaders
• Turnover of leaders may be even more
disruptive to centers
– High costs to recruit new leaders
– Increases uncertainties for program staff
– Disrupts inter-organizational linkages
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Past-Year Change in
Center Administrators
50%
40%
30%
20%
10%
0%
26.3%
Public
21.6%
Private
• About 24.0% of centers reported a change in
the administration of their center within one
year.
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The Concept of Turnover Intention
• Studies of turnover are challenging to
conduct
– Most surveys of employees are done just once, so
researchers can’t measure actual turnover
• But turnover intention has been identified as
the best predictor of actual turnover over
time
– “I am seriously thinking about quitting my job.”
– “I am actively looking for a job at another center.”
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Burnout & Emotional Exhaustion
• Emotional exhaustion as central concept of
burnout
– “I feel emotionally drained from my work.”
– “I feel frustrated by my job.”
• Certain jobs are at higher risk of burnout,
particularly those that involve “constantly
dealing with other people and their problems”
(Cordes & Dougherty, 1993)
– Doesn’t that sound like the central task of
management?
– They have to deal with funding agencies,
coordinate with other agencies, manage
employees, etc.
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Greater emotional exhaustion and
greater turnover intention is linked
to greater odds of turnover one
year later.
Emotional
Exhaustion
Turnover Intention
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+
Change in
Administrator
One Year Later
+
Change in
Administrator
One Year Later
What are the sources of turnover
intention & emotional exhaustion for
program leaders?
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Organizational Strategy
• Long tradition of studying how
perceptions of being “in control” can
enhance employee well-being
– Control over making the “big decisions”
– Control over uncertainties
• Two aspects of organizational strategy
are linked to this idea of “control”:
– Bold decision-making orientation
– Long-term strategic planning
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Bold Decision-Making Orientation
• “When confronted with decision-making
situations, this center typically adopts a
bold, aggressive posture in order to
maximize the probability of exploiting
opportunities.”
– In other words…managers have the power
to take risks
• Leaders were less likely to be planning
to quit when this orientation towards
bold decision-making was higher
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Long-Term Strategic Planning
• Long-term strategic planning may help
managers anticipate future challenges &
plan solutions in advance
– Includes financial planning, market
research and anticipating where clients will
be coming from in the long-term
– Enhances sense of control over the many
uncertainties of program management
• Results show that long-term strategic
planning reduces emotional exhaustion
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Performance Pressures
as a Stressor
• Another common theme in job stress studies
is that work-related pressure increases
burnout and turnover intention
• For managers, pressures may be related to
the financial performance of the organization
– Generating high revenues, minimizing costs, high
patient census
• Greater emphasis on these types of
performance increases both emotional
exhaustion and turnover intention
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Participative Management of Staff
• Long line of research shows that
participative management is good for
staff
– Allowing employees to make decisions
about how to perform their jobs
– Providing information to employees about
management’s decisions & asking for their
input
• But is it good for managers too?
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Centralized Decision-Making
• Centralized decision-making as the opposite
of participative management
– “There can be little action taken here until a
supervisor approves a decision.”
– “Even small matters have to be referred to
someone higher up for approval.”
• While control over “big decisions” may be
good, not letting employees have control over
the “small decisions” may increase stress:
– Higher emotional exhaustion
– Higher turnover intention
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Involving Employees
in Decision-Making
• Managers can actively involve employees in
the decision-making process
– “I make sure all employee concerns are heard
before job decisions are made.”
– “I try to clarify decisions and provide additional
information when requested by employees.”
• Managers that involve employees more in the
decision-making process reported:
– Lower emotional exhaustion
– Lower turnover intention
The University of Georgia
Summary
• Organizational strategy matters in terms of
the well-being of program managers
– They need control over big decisions
– Long-term planning can help
– Too much emphasis on (financial) performance
may be detrimental
• Participative management strategies—where
employees are more involved in decisionmaking process—may have important
benefits for the well-being of program leaders
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The Addiction Workforce:
Characteristics of Counselors
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Key Questions about the
Counseling Workforce
• Is there substantial “graying” of the
counseling workforce?
• Is counseling becoming a “female
occupation”?
• To what extent are racial and ethnic
minorities represented in the counseling
workforce?
• Is there evidence of greater workforce
professionalism?
The University of Georgia
Average Counselor Age & Tenure
• The average counselor is in their mid-40s
– Private center average = 46.4 years
– Public center average = 44.6 years
– TC average = 43.5 years
 The average American full-time worker is about 40.4 years old
• The average counselor has worked for their center
for about 4-5 years
– Private center average = 5.3 years
– Public center average = 4.8 years
– TC average = 4.3 years
 The average American full-time worker has worked for their
current employer for 8.4 years
The University of Georgia
Counselor Characteristics:
Gender
100%
75%
50%
25%
0%
64.0%
57.9%
60.1%
% Female
Public
Private
TC
• The majority of counselors are female.
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Counselor Characteristics:
Racial/Ethnic Minorities
100%
75%
50%
25%
0%
46.2%
44.1%
17.7%
% Minorities
Public
Private
TC
• Private centers employ a significantly smaller
percentage of minority counselors.
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Counselor Characteristics:
Educational Attainment
100%
75%
50%
25%
0%
47.8%
37.3%
26.4%
% MA Degree or Higher
Public
Private
TC
• Private center counselors are more likely to
have a Master’s-level degree than counselors
in public centers & TCs.
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Counselor Characteristics:
Certification in Addictions Counseling
100%
75%
50%
25%
0%
59.2%
53.1%
45.1%
Certified
Public
Private
TC
• About half of the workforce is certified in
addictions counseling, but TC counselors are
less likely to have this credential.
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Counselor Characteristics:
Personal Recovery Status
100%
75%
50%
25%
0%
53.0%
51.2%
56.5%
% Recovering
Public
Private
TC
• About half of the workforce is personally in
recovery from substance abuse.
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Counselor Turnover:
Associations with
Organizational Characteristics
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Counselor Turnover in Addiction Treatment
Programs
• Previous research shows annual turnover
rates range from 18% to 50% (Gallon et al.,
2003; Johnson et al, 2002; McLellan et al,
2003).
• Current data shows range between 13% and
21% depending on type of program
• Significantly higher than national average
across all occupations (11%)
• Higher than teachers (13%) and nurses
(12%) – occupations known for high turnover
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Comparing Voluntary Turnover
25
21
20.5
20
15
13.1
10
5
0
Public
Private
% Turnover
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TC
• Public centers
and TCs have
significantly
higher turnover
than private
centers (p<.001)
What do we know about the
differences between these types of
programs that might explain
differences in counselor turnover?
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Private Centers vs. Public Centers and
Therapeutic Communities (TCs)
Private centers
– Higher % with primary alcoholism diagnosis
– Higher % counselors with Master’s degree
– Higher average salaries
Public centers and TCs
–
–
–
–
Higher
Higher
Higher
Higher
%
%
%
%
relapsers and CJ referrals
minority clients
with primary cocaine diagnosis
minority counselors
The University of Georgia
Results
• Analysis using data from private centers
• Higher levels of turnover associated with:
–
–
–
–
For profit status
Larger capacity
Composition of workforce
Prior Turnover Rate
• Lower levels of turnover associated with:
– Counselor-management relations
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Explanation of Results – Workforce Composition
• Aspects of workforce affecting turnover
– Higher percentage of female counselors =
higher turnover
– Higher percentage of counselors in
recovery = higher turnover
– Higher percentage of minority counselors
and counselors certified in addictions =
lower turnover
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Explanation of Results – Counselormanagement relations
• Participatory management
– Center hears employee concerns before making
decision
– Receive sufficient notice of changes affecting work
– Effective channels of communication between
employees/management
• Organizational commitment
– Willing to put in extra effort to help center
succeed
– Proud to tell others I am part of this center
– This is best of all possible centers for which to
work
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What doesn’t impact turnover?
•
•
•
•
The diversity of services offered
Counselor education level
Counselor salaries
The types of patients being treated
– Relapsers, CJ Clients, Indigent, Specific
drugs
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Take Home Message
• Turnover breeds turnover – programs with high rates
have a difficult time reducing turnover
• Difficult clients are not the issue
• Money is not the issue - Increasing counselor salaries
will not reduce turnover
• The lowest turnover rates are in programs that
successfully create a smaller “family” type culture in
which counselors feel that they are able to
communicate with management and are included in
important decisions. The result is a workforce
committed to the program and willing to work hard
to see it succeed.
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Workforce Retention:
Counselors and Turnover Intention
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What management practices are
associated with lower turnover
intention?
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The Importance of
Organizational Commitment
• One idea is that if employees are committed to the
organization, then they won’t leave
– Organizational commitment as pride in working at the center
& willingness to put forth extra effort to ensure the center’s
success
• Employees will be more committed to the
organization if they feel that the organization is
committed to them
– The norm of reciprocity
• Support for these arguments in a study of private
center counselors (Knudsen et al., 2003, Journal of Substance
Abuse Treatment, 24:129-135)
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Management Practices That Build
Organizational Commitment
• Job Autonomy—authority to make
decisions about how to do one’s job
– “I have enough freedom over how I do my
job.”
• Counselors with greater control over
their jobs are:
– More committed
– Less likely to be planning to quit
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Commitment-Building
Management Practices (continued)
• Support for Creativity—managers
encourage counselors to express their
opinions and to try new ideas
– “Employees are encouraged to develop
their own ideas, even if they deviate from
those of the center’s management.”
• Counselors are more committed when
they feel that their center supports their
creativity
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Commitment-Building
Management Practices (continued)
• Performance-Based Rewards—the
center rewards hard work with
recognition, promotions, and raises
– “The amount of recognition I receive when
I do a good job is satisfactory.”
– “If I perform my job well, I am more likely
to be promoted.”
• Counselors are more committed when
centers reward job performance.
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What else reduces turnover
intention?
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Fairness in the Workplace
• Perceptions about justice and fairness within the
organization are important predictors of turnover
intention
– Sample of TC counselors (Knudsen et al., in press, JSAT)
• Procedural justice: fair processes
– “Job decisions are applied consistently across all affected
employees.”
– “When decisions are made, all the people who will be
affected are asked for their ideas.”
• Distributive justice: fair outcomes
– “The workload at this center is fairly distributed.”
– “Where you work, the amount of pay employees receive is
distributed fairly.”
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The Importance of
Workplace Fairness
• Turnover intention is lower when:
– Procedures are perceived to be just
– Outcomes (pay, workload, etc) are perceived to
be fairly distributed
• In addition, justice is linked to counselor
burnout
• Burnout is higher when:
– Procedures are perceived to be unfair
– Outcomes are unfairly distributed
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What does all this mean?
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• Workforce retention can be improved through
management practices
• Managers may benefit by thinking about
whether they:
–
–
–
–
Give counselors enough control over their jobs
Support creativity
Reward strong job performance
Solicit opinions from counselors before making
decisions
– Apply decisions consistently
– Ensure that both workload and rewards are
distributed fairly
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Clinical Supervision:
Promising Results for
Reducing Turnover Intention
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Clinical Supervision:
Is It a “Best Practice”?
• High-quality clinical supervision as having two parts:
– Supervisor can provide good advice because of his/her
expertise and training
– Supervisor does provide work-related advice that improves
the counselor’s ability to treat clients
• To date, there is little research on whether highquality clinical supervision may reduce counselor
turnover
– Such evidence might suggest that high-quality clinical
supervision is a “best practice” in program management
• CTN counselor sample was used to address this issue
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Higher quality clinical
supervision is associated
with lower turnover
intention.
-.23***
Clinical Supervision
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Turnover Intention
Why is clinical supervision associated
with turnover intention?
• Is it because the quality of clinical
supervision associated is linked to:
– Job autonomy,
– Procedural justice, and
– Distributive justice?
• Is it because clinical supervision predict
counselors’ organizational commitment
and emotional exhaustion?
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Clinical supervision is
associated with
perceptions of autonomy
and justice.
.42***
Job Autonomy
.39***
Clinical Supervision
Procedural Justice
.55***
Distributive Justice
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.176***
Clinical supervision is only
directly associated with
commitment
Job
Autonomy
Organizational
Commitment
Clinical
Supervision
Procedural
Justice
Distributive
Justice
The University of Georgia
Emotional
Exhaustion
Turnover intention is
associated with
commitment and
emotional exhaustion
Job
Autonomy
Organizational
Commitment
Clinical
Supervision
-.48***
Procedural
Justice
Distributive
Justice
The University of Georgia
Turnover
Intention
Emotional
Exhaustion
.27***
Summary of Results
• High-quality clinical supervision appears
to improve perceptions that the
workplace is fair, which then improves
commitment and reduces emotional
exhaustion
• By increasing commitment and reducing
emotional exhaustion, turnover intention
is lower
• The model suggests that high-quality
clinical supervision may be a “best
practice” of program management
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In conclusion…
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Conclusions
• Workforce retention is indeed a key
issue facing the substance abuse
treatment field
– Both for program leaders and counselors
• Attention to organizational strategy and
management styles may yield
improvement in turnover
– Emotional exhaustion and turnover
intention can be reduced
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Conclusions (continued)
• In general, treatment programs may
benefit from:
– Encouraging staff to be involved in
decision-making processes
– Distributing workloads and rewards fairly
– Improving the quality of clinical supervision
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Questions and Discussion
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Items for Discussion
• Based on your experience in your own programs,
what have been some of the main factors
contributing to the loss of counseling staff?
• Based on your experience, is the loss of
management/supervisory level staff a problem for
your program?
• Are the factors related to the loss of management
level staff similar to those of counseling staff?
• Have any of you taken steps within your own
program that resulted in improved workforce
retention?
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