Competing in the “war for talent” in nursing homes: A quantitative investigation

Abstract

Purpose

This study explores the characteristics of primary care organizations that are likely to attract and retain highly skilled professionals, meeting their expectations and increasing Person-Organization fit. Both “hard” dimensions (ownership) and organizational/managerial traits under the span of control of management are investigated. The objective is to raise awareness on how to mitigate unpopular features of primary healthcare organizations so to effectively compete in the war for talent.

Methods

This study has been carried out based on data extrapolated from a broader study conducted by the Italian National Agency for Regional Health Services and commissioned by the Italian Ministry of Health. Data deriving from Italian nursing homes was extrapolated from the broader public dataset and multiple regressions were carried out to detect associations between managerial variables and staff seniority.

Findings

Several significant associations were detected, suggesting that both physicians and nurses are affected by some investigated variables when deciding where to work and for how long. While some of these are common to the two categories of professionals (e.g., the presence of a nursing director), others are not (e.g., the presence of internal training programs).

Original value

The implications of this study are related to the need of increasing awareness of managers of nursing homes on those features that are likely to increase their attractiveness and long-lasting appeal to professionals. This is a paramount topic in times in which the war for talent is strong. A lack of attention on this field may lead to the inability to attract and retain staff in primary care settings and, in turn, to implement strategic trends of change healthcare systems are facing in Italy and worldwide.

Keywords

Nursing homes person-organization fit war for talent Italy

Introduction

Healthcare systems worldwide are urged to update their managerial approaches to attract, retain and train health professionals. In 2006, the World Health Organization¹ identified the countries that met health professionals’ shortages and were incapable of reaching 80% coverage of facility-based deliveries. These were defined countries with “critical shortages” of personnel and were provided with recommended key interventions to attract and retain health workers.²

If attracting and retaining competent professionals is challenging across a vast range of healthcare organizations, this is particularly true in nursing homes, traditionally characterized by organizational environments that tend to be less appealing than those of secondary or tertiary, larger organizations.³ There are several factors that make it difficult to recruit and retain health personnel in nursing homes. These include high working hours, lower pay,⁴ low public and professional perceptions of working in them,⁵ and lower investments if compared to other sectors.⁶

These issues come at a time when patients of nursing homes are doomed to increase dramatically over the next 20 years, with a projected increase of 127%⁷ and an overall outburst of frail and chronic patients. Indeed, chronic disease and co-morbidity are becoming increasingly common worldwide, resulting in additional demand for access to allied health for chronic disease management, including early intervention,⁸ and greater pressure on long-term care facilities^9,10

In the United Kingdom, for example, there is an average staff turnover of 31.5% in nursing homes and 29.6% in care homes without nursing (often referred to as residential homes), and there is an estimated staff vacancy of 35,500 professionals across the sector.¹¹ Health workforce planning is challenging worldwide, and nursing homes frequently seem to adopt a “reactive” rather than a “proactive” attitude in attracting and retaining competent staff.¹² This implies increasing the likelihood of assigning positions to non-optimal professionals or even of dealing with uncovered positions and, in turn, of facing persistent barriers in organizations’ capability of implementing their strategies and of performing adequately.^13,14

Therefore, it is paramount that nursing homes adapt to this challenging scenario and design or re-design their main features in such a way as to become appealing for professionals. Building on Person-Organization (P-O) fit theory, this “proactive” approach has the potential to provide organizations with their most precious, yet so scarce resource: competent professionals.

Theoretical background

Attracting and retaining staff in primary care settings is challenging.¹⁵ Nevertheless, this constitutes a dramatic barrier to the strong transformations healthcare systems worldwide are currently experiencing. Many of these are re-focusing on primary care (as opposed to hospital-centric systems) which is no longer considered an ancillary part of the system that simply “integrates” services provided by hospitals.¹⁶ Quite on the contrary, epidemiological, sustainability and technological features all converge towards the need of primary care-focused healthcare systems.¹⁷ The recent pandemic has revealed the dramatic consequences of not disposing of structured and fully effective primary care health services, with highly hospital-centric systems facing strong challenges in managing the emergency.¹⁸ In this scenario, it is crucial to design and develop primary care organizations that are truly attractive to competent professionals.

In general, the attractiveness of organizations has captured the attention of scholars across countries and fields. For example, studies exploring the attractiveness of multinational corporations¹⁹ as well as of organizations in the public sector²⁰ have highlighted the existence of a “war for talent”,^21,22 with organizations facing big problems in identifying, attracting, and competing for talented employees. Strategic talent management (i.e., the systematic identification and development of talent) is key to organizational performance.^23,24 Literature has testified that organizational and job attributes have strong influence on attracting job-seekers.^25,26 These include, for example, extrinsic factors such as high pay and training opportunities.^25,27

Anyhow, literature generally postulates that people are not randomly assigned to organizations but rather select themselves into and out of them.²⁸ This is the basic proposition of the “Attraction–Selection–Attrition” framework that directs the attention to individuals’ self-selection into settings they want to work in and out of settings they do not like.

To develop a more systematic and comprehensive framework for assessing organizational attributes that predict attraction, Berthon et al. developed the Employer Attractiveness Scale. Its 25 items assess five dimensions (1): economic value (basic salary, overall compensation, job security and promotion opportunities) (2): development value (supporting employees’ personal and career development) (3): interest value (supporting novel work practices and forward thinking, and valuing and making use of employees’ creativity in the production of high quality products and services) (4) social value (providing a positive and pleasant social environment for employees); and⁵ application value (being humanitarian and customer-oriented, and providing opportunities for employees to apply their knowledge, teach others, and experience acceptance and belonging).

In more general terms, P-O fit theory contends that staff responds more favorably to organizational practices that are consistent with their values, goals, and motivations.²⁹ In other words, employees are more likely to accept to work in an organization, to improve their attitude towards it (Kristof, 1996) and to stay in it longer^30–32 if they feel that the culture and conduct of the organization is right and contributes to employee well-being. Two levels of “compatibility” can be distinguished: fit can be supplementary or complementary.^33–36 Supplementary fit is the case if a person feels to have similar culture, norms, values, or goals as the organization.^33–35 Complementary fit implies that the employer provides what the job applicant wants. This means, from the potential applicant’s perspective, that the subjectively relevant working conditions are met by the employer.

The positive outcomes of this relationship are supported by literature and studies have detected positive associations between P-O fit and, for example, job satisfaction and organizational performance.^37–43 Studies have also revealed negative associations between P-O fit and employee turnover^44–48

With specific reference to the public administration sector, public service motivation may play a greater role in job-seekers if compared to traditional work motives influencing employer attraction and job choice^49,50 Public organizations possess features that are “unique to public institutions that energize and direct behavior”.⁵¹ The needs to be satisfied due to this predisposition can have different sources: self-interest, emotional attachment, and moral or norm-based obligation.⁵² The term public in this scenario does not necessarily imply that a person works in the public sector specifically but refers “generally to motives associated with serving the public good” which is also possible in the private or nongovernmental sector.⁵¹

Even more in detail, P-O fit has been studied within the healthcare sector. Here literature has confirmed that P-O fit leads to higher effort and commitment⁵³ and, in turn, to higher performance of professionals.⁵⁴ The effects of a good fit are so powerful that they can even partially overcome the negative effects of high involvement work practices, reducing emotional destress and de-personalization of professionals at high risk of burnout.⁴⁷ It is confirmed that a good P-O fit increases job satisfaction and reduces turnover rates.⁵⁵ Moreover, studies suggest that P-O fit increases professionals’ inclination to adopt innovative working behaviors. This has direct implications on their availability of accepting and implementing change, affecting the probability of organizations to successfully implement change management. Finally, P-O fit should be intended as a permanent condition (and not only referred to the initial attraction of employees), which needs to be supported and developed in time for it not to wane.¹⁹ In other words, the compatibility between organization and individual should occur in every moment of their relationship, from the moment in which the employee chooses the specific organization, to the prosecution of his/her permanence in it in time. Most studies on P-O fit confirm this duality, either explicitly or implicitly, by associating P-O fit to both outcomes related to attractiveness as well as to an employee’s loyalty (e.g., turnover rate, job satisfaction, individual well-being). Very attractive organizations that are, however, unable to retain their human resources, may be ultimately labeled as with a poor fit.

Although P-O fit is clearly a highly desirable construct in healthcare organizations, it is to date unclear how exactly this can be obtained, especially in organizations generally characterized by low attractiveness such as primary healthcare organizations and nursing homes. More specifically, P-O fit may be linked to both attractiveness and retention (long-term attractiveness) of nursing homes. Not only does this constitute a literature gap, probably due exactly to scholars’ limited attention on primary care settings as compared to secondary and tertiary ones, but it also creates a concrete problem across healthcare systems, testified by the substantial difficulty of hiring and retaining qualified personnel in these settings.⁵⁶ This issue must be dealt with in a timely way if healthcare systems worldwide are to implement their transitions towards primary-focused approaches.

This study is aimed at exploring the characteristics of primary care organizations that are likely to retain highly skilled professionals, meeting their expectations and increasing complementary P-O fit. Though both attractiveness and retention play a role in defining an organization’s power in the war for talent, due to the nature of this study only retention is linked to such characteristics. Both “hard” dimensions (ownership) as well as organizational/managerial traits under the span of control of management are investigated. The objective is to raise awareness on how to mitigate the unpopular features of nursing homes so to effectively compete in the war for talent.

Methods and study design

This study has been carried out based on data extrapolated from a broader study conducted by the Italian National Agency for Regional Health Services. The national study was aimed at collecting data from all healthcare settings in Italy to analyze the composition and characteristics of their workforce, as well as other structural and organizational features. The broader study collected data from all providers of healthcare services in all 20 Italian regions.

In the present study, conducted from September to November 2021, through an ad hoc survey consisting of 57 questions, data deriving from Italian nursing homes has been extrapolated from the broader public dataset. The link to the survey was sent by email to a contact person working in each Region of Italy. This person was then asked to send out the survey to each nursing home present in the Region, with a presentation letter provided for this purpose. Respondents were professionals covering top managerial positions within their nursing home. Replies were finally collected online directly by the Italian National Agency for Regional Health Services.

Replies from a total of 1509 nursing homes in 19 regions/autonomous provinces have been collected. In particular, the questions addressed the following aspects, which were then used to build the variables of the study:

• Mean seniority of physicians: This is a dependent variable and is considered a proxy of the attractiveness of the working positions and of professionals’ willingness to stay.⁵⁷

• Mean seniority of nurses: This is a dependent variable and is considered a proxy of the attractiveness of the working positions and of professionals’ willingness to stay.⁵⁷

• Type of setting: It is a dummy variable which may assume value 0 (public) or 1 (private). This is a control variable.

• Training programs: This variable explains whether the nursing home provides its own internal training program or not. This is a dummy variable which may assume value 0 (no) or 1 (yes). It is an independent variable.

• Presence of nursing director: This variable explains whether the nursing home has formally introduced a professional figure that is responsible of leading all nurses. This is a dummy variable which may assume value 0 (not present) or 1 (present). It is an independent variable.

• Use of electronic health records: This is a dummy variable which may assume value 0 (not present) or 1 (present). It is an independent variable.

• Use of telemedicine: This is a dummy variable which may assume value 0 (not used) or 1 (used). It is an independent variable.

• Nurse night shift: This variable explains whether at least one nurse is on shift at night. This is a discrete variable that may assume value 0 (no nurse is regularly on shift at night), one (one nurse is on shift at night), 2 (more than one nurse is on shift at night). It is an independent variable.

• Healthcare assistant night shift: This variable explains whether at least one healthcare assistant is on shift at night. This is a discrete variable that may assume value 0 (no assistant is regularly on shift at night), one (one assistant is on shift at night), 2 (more than one assistant is on shift at night). It is an independent variable.

The assumption is that each independent variable may affect the willingness of professionals to work (and stay longer) in the nursing home through complementary fit. By providing professionals with items or working conditions that are possibly closer to their expectations and make their work either easier or more effective, nursing homes can increase such fit and ultimately remain more professionally attractive. For example, guaranteeing the presence of specialized professionals at night may reduce complications and, in general, reduce work burden in morning shifts. Similarly, the presence of training programs within the nursing home may provide professionals with more accurate competencies compared to their tasks. Associations between staff seniority and independent variables were explored to detect which characteristics of nursing homes can affect personnel’s willingness to stay.

After multicollinearity check, two multiple linear regressions were carried out with dependent variables “mean seniority of physicians” and “mean seniority of nurses” respectively. Independent variables were made up of all the remaining items. Type of setting was considered a control variable, which cannot be affected by managers’ strategies and decisions. Statistics were performed in STATA 15.

Findings

The responses from 1509 nursing homes provide a response rate of 11.9%, considering the presence of 12,630 nursing homes in Italy, at the end of 2021.⁵⁸ Descriptive statistics are presented in Table 1.

Table 1.

Descriptive statistics.

Variable	Configurations	Percentage (%)
Geographical location	Northern Italy	74
	Central Italy	17
	Southern Italy	9
Ownership	Private	78.5
Ownership	Public	21.5
Training provided	Yes	86
Training provided	No	14
Presence of nursing director	Yes	15
Presence of nursing director	No	85
Use of electronic health records	Yes	47.6
Use of electronic health records	No	52.4
Use of telemedicine	Yes	19.4
Use of telemedicine	No	80.6
Nurse night shift	Yes	29.4
Nurse night shift	No	70.6
Healthcare assistant night shift	Yes	36
Healthcare assistant night shift	No	64

The results deriving from the regressions of physicians’ and nurses’ seniority are reported in Tables 2 and 3 respectively. In the first case, significant associations (p-value = 0.05) were detected for the variables type of setting, training programs, presence of nursing director, use of telemedicine, nurse night shift, health care assistant night shift.

Table 2.

Regression analysis for seniority of physicians.

Table 3.

Regression analysis for seniority of nurses.

In reference to nurses, significant associations (p-value = 0.05) were detected for the variables type of setting, presence of nursing director, use of electronic health records (p-value = 0.1), nurse night shift, health care assistant night shift (p-value = 0.1).

Discussion

Several significant associations have been detected both referred to the mean seniority of physicians and of nurses in Italian nursing homes. In both cases the type of setting appears to affect professionals’ willingness to stay, with public nursing homes systematically perceived as more attractive than private ones. This can be explained by the fact that in the Italian healthcare scenario, made up of both public and private providers of care (with the latter frequently operating on behalf of the public system), being employed by a public organization is possibly perceived as safer. Prior studies have confirmed that employment in the public healthcare sector is frequently associated to greater stability and career options.⁵⁹ Nevertheless, this variable must be interpreted as a control item since it cannot be affected by the managerial approaches in the nursing home itself.

The presence of internal training programs seems to affect physicians’ seniority. Interestingly, the coefficient assumes a negative value, suggesting that internal training is negatively associated to willingness to stay. Though it is important to better explore why this is the case with specific research on the topic, it may be the case that training activities are not always perceived as truly relevant by these professionals. As mentioned, professionals are required to update their competencies by law (and, hence, must reach a certain number of “credits” per year), but it may be the case that they value the possibility of choosing where to be trained and perceive internal training as a burden that does not meet their expectancies.

The presence of a nursing director is positively associated to seniority of both physicians and nurses. This suggests that formalizing the assignment of responsibility and accountability for all nurses to a specific and accordingly trained professional is felt to improve working conditions of both categories. The risk of increasing the hierarchy by introducing an additional professional figure seems to be overcome by the benefits of delegating responsibility to him/her.

The structured use of telemedicine is negatively associated with physicians’ seniority. Again, the reasons behind this association may require further investigations in dedicated studies. However, it is interesting to note that this may be connected to a general resistance of physicians to shift towards new ways of providing care, possibly fearing negative consequences on the quality of their interventions and on the relationship with their patients. Interestingly, this negative association is not detected for nurses, who therefore seem to better accept the use of this revolutionary technology.

For both categories of professionals, a positive association between the stable presence of nurses on night shift and their seniority is detected. This might mean that the stable basis of an assistance provided by professionals with clinical competencies may imply an overall better management of patients and less situations of stress for staff, especially when taking on the morning shift.

Finally, a negative association between the stable presence of healthcare assistants at night and the seniority of both professionals is assessed. Though not completely intuitive in principle, this may be interpreted as a situation in which at night patients are entirely entrusted to professionals with no clinical competencies, strengthening situations of stress for morning staff, as for the previous variable.

Based on the assumption that seniority may be used as a proxy of willingness to stay, interesting patterns that feed the P-O fit theory in nursing homes emerge. The independent variables of the study allow to understand how some key managerial decisions affect the attractiveness of nursing homes to workers. While some of these determinants are common to physicians and nurses, others are not, suggesting that these categories conserve their unique traits and features when deciding on whether to stay or not in an organization.

These considerations are key in the deeper scenario of evolving healthcare systems. Current epidemiological, financial, and technological pressures are leading healthcare systems towards models that are more and more based on primary-centric visions. For example, community health, declined in new proximity settings that are meant to reach patients as close as possible to their daily lives and homes, are frequently considered key in the development of new effective and sustainable configurations of healthcare systems.⁶⁰ If this organizational revolution is to take place, it is fundamental that health workforce is aligned with and willing to work in such new settings, covering new roles and responsibilities. Therefore, questioning the attractiveness of nursing homes, or of non-hospital settings in general, is possibly the first step in supporting the main trends of change that are likely to characterize healthcare systems worldwide in the near future.

Practical implications and limits

The practical implications of this study are related to the need of fostering awareness of managers of nursing homes on those features that are likely to increase their attractiveness to professionals.⁶¹ This is a paramount topic in times in which the war for talent is very strong in the healthcare sector in general, but even more so in nursing homes and in primary healthcare settings, which are frequently the least appealing settings for doctors and nurses. A lack of attention in this field may ultimately lead to drastic consequences, such as the inability to attract and retain staff in primary care settings and, in turn, to implement many strategic trends of change healthcare systems are investing on in Italy and in the rest of the world.

Future studies should build on this preliminary evidence, addressing other items that are likely to affect P-O fit in this sector. A highly relevant topic is surely related to the evolution of professional and competency profiles.⁶² Both physicians and nurses (and other professionals) are likely to face changing roles in the next decades. If organizational models are doomed to change, so are the responsibilities of the professionals called to populate them. For example, nurses are already dealing with different approaches to assistance (i.e., functional, primary, modular assistance models), that are deeply affecting their role and the required competency mix. P-O fit is likely to depend also on the configurations of professional roles and their coherence with the objectives of health settings. Similarly, career opportunities, wages, working conditions and related factors are all items that are likely to affect the attractiveness of settings.⁶³

A few limits of study deserve mentioning. First, the study is carried out in one country only. Nevertheless, the Italian National Healthcare System and many of its challenges are similar to those of many other Western countries. Major issues such as ageing population⁶⁴ putting pressure on healthcare systems that must consequently re-think their configuration and overall strategy are common to most countries, if not continents across the world.^65,66 The great numerosity and representativeness of data at the national level make results robust and of interest for international comparison. Future studies should, however, replicate or adapt the investigation in other nations.

It was not possible to directly assess the attractiveness of nursing homes for professionals, hence seniority was used as a proxy. Though this is possibly a limit of the study (seniority may be affected by other dimensions that are not taken into account in this work, like e.g. socio-economic conditions of the area, competitiveness in the sector), seniority may be held as a good approximation of attractiveness and willingness to stay, given that professionals are highly requested in these settings and are likely to be in possess of valid alternatives to their current working place.

In general, this study provides managers of nursing homes and of other primary care settings with a better understanding of the tools they must use to compete in the war for talent. Its originality lies in its specific attention to unattractive working settings which are, however, strategic in most healthcare systems, constrained by decreasing resources and increasing chronicity and multimorbidity to be managed. Moreover, it adopts an approach that differentiates professional categories’ points of view, highlighting the need to tailor scientific investigations and managerial practices to their peculiarities. It provides specific suggestions on how to address knowledge gaps in this field such as, for example, deepening our understanding of pros and cons of using telemedicine from professionals’ perspectives and provides managers with a framework to assess the strengths and weaknesses of their organization. These findings are of interest to an international audience, given the common challenge of retaining skilled professionals in scarcely appealing working contexts and of contrasting health workforce shortages. Indeed, no long-term success can be achieved without an adequate team of professionals willing to invest in the organization in a long-term perspective.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Irene Gabutti

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