How Teams Are Engaging and Retaining Direct Care Workers

Initiatives aiming to improve staff retention often focus on the individuals in those roles, instead of improving the system and environment in which they work. Yet the data shows us these are system level issues. For example, in 2024, turnover among Patient Care Technicians was more than 34 percent and for Certified Nursing Assistants (CNAs) it reached more than 36 percent. CareFront, an IHI-led initiative, aims to reduce turnover in these roles. With funding from the Ralph C. Wilson Jr. Foundation, we are testing a theory of change that creates the conditions for health care workers at all levels to feel valued and thrive in a collaborative environment. 

Direct care workers (DCWs) such as Patient Care Technicians and Certified Nursing Assistants provide hands-on care and support. A lack of recognition, low pay, inflexible work schedules, and challenging staffing ratios are among the challenges leading to high turnover rates among these vital members of the health care workforce.

CareFront’s work began in March 2023 through a 90-Day IHI Learning and Testing Cycle to structure an inquiry into promising innovations. Through this process, which included synthesis of existing literature and materials, key informant interviews, and collaboration with subject matter experts, the team developed a theory of change that reflects key drivers of DCW retention and associated change ideas.

Together with six hospitals and one nursing home participating in CareFront, IHI is learning about and refining the theory of change and building a set of tools and resources. Fourteen months into the 22-month collaboration with the sites, a few fundamental concepts have emerged:

Engaging direct care workers in developing and testing solutions is perhaps the most impactful step teams have taken in their CareFront work. Engagement informs all other efforts to achieve retention goals. Each participating team includes one or more DCW as part of the multidisciplinary core team leading improvement work. DCWs bring subject matter expertise about their roles, provide important perspective in choosing and designing tests of change, and bolster credibility of the team with other direct care workers. Engaging DCWs as key members of the team also leads to other types of engagement, benefiting the organization and improving staff experience. For instance, direct care workers are joining and contributing to shift huddles and taking on leadership and mentorship within their DCW roles.

Building trust and demonstrating real and active partnership across roles and disciplines was a vital first step. Teams embraced the challenge of asking workforce members what matters most to them (that is, “What brings you joy in work each day?”; “What are the ‘pebbles in your shoes’?”), collecting suggestions about what changes direct care workers most wanted to test, prioritizing them, and then acting quickly to put ideas into action. Deferred or deprioritized ideas were recorded for future consideration. Teams used visual displays of their tests of change in workforce common areas so people could track progress and remain engaged in contributing ideas and feedback. This creates a virtuous circle – change ideas are most relevant when they are suggested or enhanced by those whom they will most impact, while showing that good ideas will be tested and implemented in a timely way drives further engagement and builds will for improvement.

Ensuring that direct care workers have the knowledge and resources they need to do their jobs efficiently and well emerged as another key concept. One team learned that DCWs often did not have the linens they needed on the unit, which caused delays and frustration. The team worked with their facilities department to improve the process and ensure that linens are reliably delivered timely to the unit in the appropriate quantities. Extending high reliability organizing to DCWs improves reliability of patient flow, patient experience, workforce experience, and alignment to purpose. Another team learned that direct care workers temporarily assigned to other floors or units as float staff were often unfamiliar with the policies and procedures of that unit. The team developed a “Float Guide” as a quick reference, had a few staff test the guide and suggest edits, and are working to spread the concept to other units in their hospital. 

These lessons from the CareFront initiative have proven valuable, with promising early results. Several pilot units are showing improved retention of direct care workers, and most have started to spread successful change ideas to other units in their facility. Actively and intentionally improved environment and teamwork are contributing to patient outcomes, including, in some cases, reduction in patient falls and reduction in rates of central line-associated blood stream infection (CLABSI). 

As the theory of change and related tools and resources are refined, we will share them via IHI Insights, newsletters, and conferences. To hear directly from some of our CareFront team members, watch this short video.

This project is funded by The Ralph C. Wilson, Jr. Foundation. Thank you to the foundation for their support and to the dedicated teams partnering with us to learn about improved retention of direct care workers: Catholic Health, Henry Ford Health Wyandotte Hospital, Henry Ford Health St. John Hospital, Rochester Regional Health, Trinity Health, University of Rochester Medical Center, and Wyoming County Community Health System. 

Joelle Baehrend, MA is a Senior Project Director at IHI.

Photo by Freepik

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