presentation

The University of Georgia

Workforce Retention in Addiction Treatment:

Findings from the National Treatment Center Study

Paul M. Roman, Principal InvestigatorCo-Investigators: Aaron Johnson, Hannah K.

Knudsen, and Lori J. Ducharme

This research is supported by NIDA Research Grants R01DA13110, R01DA14482, &

R01DA14976


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


The National Treatment Center Study:

An Overview


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


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


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

non-profit programs that rely on public funding

– Average center receives 84% of its funding from public sources


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


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


NIDA’s Clinical Trials Network• The CTN is a research network that links

university-based researchers with community-based 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


Types of Programs NOT in the NTCS

• Programs based in correctional settings

• VA programs• Halfway houses & transitional

housing• DUI services• Counselors in private practice


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


The Addiction Workforce:Characteristics of Leaders


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


Leader Characteristics:Gender

47.2% 45.7%0%

25%50%75%

100%

% Female

Public Private

• Nearly half of program leaders are female.


Leader Characteristics:Racial/Ethnic Minorities

22.4%8.5%

0%25%50%75%

100%

% Minorities

Public Private

• Public centers are more likely than private centers to have a leader with minority background.


Leader Characteristics:Educational Attainment

64.1% 69.6%

0%25%50%75%

100%

% MA Degree or Higher

Public Private

• The majority of leaders have at least a Master’s-level degree.


Leader Characteristics:Personal Recovery Status

35.5% 38.0%0%

25%50%75%

100%

% Recovering

Public Private

• About one-third of leaders are personally in recovery from substance abuse.


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)


Workforce Retention “At the Top”:

Turnover Intention and Emotional Exhaustion Among Program Leaders


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


Past-Year Change in Center Administrators

26.3%21.6%

0%10%20%30%40%50%

Public Private

• About 24.0% of centers reported a change in the administration of their center within one year.


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.”


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.


Change in Administrator

One Year Later

EmotionalExhaustion

+

Greater emotional exhaustion and greater turnover intention is linked to greater odds of turnover one year later.

Turnover IntentionChange in

AdministratorOne Year Later

+


What are the sources of turnover intention & emotional

exhaustion for program leaders?


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


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


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


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


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?


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


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


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 decision-making process—may have important benefits for the well-being of program leaders


The Addiction Workforce:Characteristics of Counselors


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?


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


Counselor Characteristics:Gender

64.0% 57.9% 60.1%

0%25%50%75%

100%

% Female

Public Private TC

• The majority of counselors are female.


Counselor Characteristics:Racial/Ethnic Minorities

46.2%

17.7%

44.1%

0%25%50%75%

100%

% Minorities

Public Private TC

• Private centers employ a significantly smaller percentage of minority counselors.


Counselor Characteristics:Educational Attainment

37.3% 47.8%26.4%

0%25%50%75%

100%

% 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.


Counselor Characteristics:Certification in Addictions

Counseling

53.1% 59.2%45.1%

0%25%50%75%

100%

Certified

Public Private TC

• About half of the workforce is certified in addictions counseling, but TC counselors are less likely to have this credential.


Counselor Characteristics:Personal Recovery Status

51.2% 53.0% 56.5%

0%25%50%75%

100%

% Recovering

Public Private TC

• About half of the workforce is personally in recovery from substance abuse.


Counselor Turnover:Associations with

Organizational Characteristics


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


Comparing Voluntary Turnover

21

13.1

20.5

0

5

10

15

20

25

Public Private TC

% Turnover

• 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?


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 % relapsers and CJ referrals– Higher % minority clients– Higher % with primary cocaine diagnosis– Higher % minority counselors


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


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


Explanation of Results – Counselor-management 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


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


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.


Workforce Retention:Counselors and Turnover

Intention


What management practices are associated with lower turnover

intention?


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)


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


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


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.


What else reduces turnover intention?


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.”


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


What does all this mean?


• 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


Clinical Supervision:Promising Results for

Reducing Turnover Intention


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 high-quality 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


Turnover IntentionClinical Supervision

-.23***

Higher quality clinical supervision is associated with lower 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?


Distributive Justice

Job Autonomy

Procedural JusticeClinical Supervision

.42***

.39***

.55***

Clinical supervision is associated with perceptions of autonomy and justice.


Clinical Supervision

Job Autonomy

Procedural Justice

DistributiveJustice

OrganizationalCommitment

EmotionalExhaustion

.176***Clinical supervision is only directly associated with commitment


Clinical Supervision

Job Autonomy

Procedural Justice

DistributiveJustice

OrganizationalCommitment

EmotionalExhaustion

TurnoverIntention

.27***

-.48***

Turnover intention is associated with commitment and emotional exhaustion


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


In conclusion…


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


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


Questions and Discussion


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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