Self-directed work groups eliminate turnover

Paraprofessionals give managers more control

Self-directed work teams may dramatically lower paraprofessional turnover in your organization. Consider the case of Boise, ID-based St. Alphonsus Home Health. Since implementing a self-directed work team system among home health aides (HHA) about five years ago, the agency reduced turnover to virtually zero.

"People only leave when they move out of the area or graduate from nursing school," says Alice Ennis, MSN, RN, C, clinical manager.

Such dramatic results are no fluke, according to Ennis. They are not only possible, but even probable for other providers who make a commitment similar to the one St. Alphonsus made when initiating the system, she says.

With a team-oriented managerial philosophy supporting them, the self-directed HHA work group initially underwent an extensive training program and developed a profile of an ideal HHA. Today, they schedule themselves and participate in monthly educational and problem-solving meetings and now-infrequent HHA candidate interviews.

Take control

The idea for the new approach came from Ennis’ attendance at a nursing conference that emphasized the importance nurses place on having control over their work life, combined with some research she’d seen about nursing homes lowering turnover by encouraging certified nursing assistants to participate in the organizations.

"It just seemed like a natural thing to do. We tried to develop a climate where people are responsible for their own destiny. We like people to develop as much as possible," she says.

St. Alphonsus’ self-directed work group (SDWG) process began with management and licensed staff education. "This has to be consistent with managerial values and climate, and the licensed staff have to understand and embrace it," Ennis explains.

Next came setting the organizational culture with a new mission statement: "We strive to create together a work environment that is affirming of individuals’ worth and self-esteem and that reflects trust and mutual respect."

The entire organization had a hand in developing it. "It applies across the board. It’s part of our everyday life, not just the home health aide’s," Ennis says.

From there, an extensive HHA education program began. It covered interviewing skills, group dynamics, assertiveness, communication, delegation style, and problem solving, and totaled about 10 hours for each HHA. At the end of the training, the HHAs developed an ideal HHA profile to use in hiring new employees.

Profile components include:

    • maintaining personal and professional boundaries between oneself and your client;
    • being non-judgmental and non-threatening with patients and co-workers;
    • having good interpersonal skills;
    • understanding and supporting patient independence.

The profile served dual purposes. It not only outlined expectations for job candidates, but also established standards for existing employees. "It gave peer pressure. If this is what I want you to look like, this is what I’m going to do," Ennis explains. St. Alphonsus added the profile to its other employment standards, which include:

    • background checks;
    • completion of application;
    • previous HHA work experience;
    • reference checks.

Find the right person

Existing HHAs evaluate applicants against the profile through a series of prepared questions asked in group interviews. Ennis advises applicants beforehand that they will meet with herself and up to five other HHA-employees. The questions are designed to determine the applicant’s problem-solving approach and run the gamut of patient care situations.

For example, one asks what the applicant would do if she entered the home of a client who was crying and saying she’d just had an out-of-body experience. "We’re looking for someone who takes a minute and thinks about how to respond to a bizarre situation," Ennis explains.

On the other hand, when asked what she would do if she found a patient unresponsive, "We want someone who would jump in. We want someone who know the difference [between the two situations]."

Although Ennis makes the final hiring decision and job offer, she relies on the recommendation of the HHA-interviewers. They discuss their impressions of how a candidate fits into the profile immediately after each interview. "This is where we started setting the standard for new employees, [including] mutual respect and trust," she says.

Once hired, new employees again interact with existing HHAs. A lead HHA puts the orientation calendar together and arranges for the orientee to shadow as many HHAs as possible. They all give feedback about the new employee’s performance and help develop a performance plan. "This gives them ownership in making sure the orientee succeeds," according to Ennis.

In addition to hiring and orientation, the self-directed work groups participate in St. Alphonsus’s performance improvement committees and handle patient scheduling themselves. The agency has a scheduler who makes the initial case assignment based on geographic zones. However, if a HHA can’t work the patient’s desired visit times into her schedule, or feels she needs a break from a particularly trying case, she may negotiate and trade assignments with another HHA. In such circumstances, the HHA usually turns to her peer in the adjacent territory. The system works very well, according to Ennis.

"I can’t say there’s never been problems, but it usually happens when someone interferes with them," she says.

The HHAs also switch territories every quarter. "It makes the job more interesting for the HHAs, it cuts down on burnout, and it [keeps] patients [from being] too dependent on one HHA," Ennis explains.

The self-directed work groups meet formally every month for continuing education and to discuss any problems or concerns. They also participate in weekly team conferences, and through daily trips to the agency offices, have an ongoing opportunity to interact and address any issues.

Although the self-directed work groups have been very successful over time, they initially caused much upheaval. "The first six months we had a huge turnover. The existing people left. They didn’t want to go through it, and they didn’t trust the people they were hiring. But you have to trust that people want to do their best," she says.

Those who stuck it out reaped both professional and personal benefits. Ennis recounts the "very powerful effect" on the group of seeing how an assertiveness workshop influenced a team member who had previously been the least assertive among them. "I’m very gratified to see that they’ve grown as individuals as well as directing their work," says Ennis.

In addition to the time and resource commitment, the work groups require a significant, but ultimately rewarding change in management philosophy.

"It takes a definite mindset change. It’s hard to let go. It’s hard to let them decide what they’re going to do. [Managers think] you’re supposed to control. But I feel I now have more control over their everyday work habits," she says.


Alice Ennis, MSN, RN, C, Clinical Manager, St. Alphonsus Home Health, 427 N. Curtis, Boise, ID 83706. Telephone: (208) 367-7302.