As the nation navigates the Great Recession, millions of people are unemployed. Meanwhile, the demand for “care” workers is booming, but job turnover rates are alarmingly high. What’s wrong with this picture? Pitt business professor Carrie Leana has been examining some of these issues, with timely and intriguing results.
Written by Elaine Vitone
The newly minted MBA graduate takes a job working for a large commercial bank in Houston, Texas. She’s quickly bored by the mindless numbers crunching and sea of paperwork. But she’s fascinated by workplace behaviors. The bank isn’t the static environment she expected. Instead, individuals continually reshape their jobs, and the work, in turn, shapes behaviors. She’s especially intrigued by the interplay of organizational expectations and individual responses. It’s clear to her that these interactions are central to success—or failure—in the business world.
Both the tedium of the formal work and the discovery of the informal behavior “hidden in plain sight” at the bank job prompt Carrie Leana to shift from pursuing accounting and finance to a PhD degree in the then-emerging field of organizational behavior and management, initiating a careerlong interest in organizational change. What she has since observed, across many different industries and job sectors, is that individual and organizational success both depend on more than just wages, skill sets, and job openings. They depend, fundamentally, on a delicate balance between stability and change—something that is essential as the nation struggles with high unemployment rates.
Leana joined Pitt’s business faculty in 1988 during a period of devastating labor unemployment after the region’s steel industry collapsed. She came to Pitt from the University of Florida to expand her academic research on the process and effects of organizational change in settings ranging from steel mills to public schools, and child care centers to nursing homes.
“What really interests me is looking at how and why—other than a paycheck— people work. Work practice and work organization are, in a nutshell, what I study,” says Leana, who is the Katz School’s George H. Love Professor of Organizations and Management.
One of the insights she has gained is that the rules governing employment and job turnover don’t necessarily follow conventional thinking about labor supply and demand. Traditional perspectives on employment tend to focus on what economists and business scholars call “human capital”—factors that involve specific skills and job mastery. But Leana’s research points to less obvious ingredients that are also essential for business success.
Throughout her academic career, Leana has documented the toll of workplace instability. In the fallout of unemployment and high staff turnover, employers lose not only the skills and training of each worker—the human capital—but also the efficient, practiced way each group learns to work together, a concept she calls social capital. Leana describes this concept as the efficiencies on the job that workers develop about “who knows what” and who can help them learn the way things really get done—around, and sometimes in spite of, the formal organizational chart. It’s these insider shortcuts, she says, that are the hidden value of social capital. The loss of this value can be debilitating to an organization plagued by high turnover.
In recent years, Leana has begun to explore the workplace world of direct-care workers—those involved in the frontline care of children, the elderly, and the chronically ill. These positions demand personal face-to-face interactions, with a great deal of emotional and physical labor, yet the workers are typically underpaid and undervalued. The growing demand for these workers is creating an urgent need to find better ways to recruit and retain them, especially in the field of health care.
In the United States, the workforce of Certified Nursing Assistants, or CNAs, is alarmingly unstable, with an average facility turnover rate ranging from 40 percent to an astonishing 100 percent a year. Staffing shortages will worsen as Baby Boomers grow older and their health care needs increase. A 2008 report by the Institute of Medicine cited CNA shortages as a key factor in an impending crisis in elder care. While low pay contributes to these shortages, it is not the only factor. Instead, Leana sees low pay as a symptom of the larger societal tendency to undervalue care work.
Articulate and amiable, with a Let’s-get-things-done-here attitude, Leana says that a shortfall in people to fill these occupations is a predictable result of our failure as a society to reassess traditional notions about work historically done in the home by women or by low-paid servants. Such shortages, and our unwillingness to address the fundamental causes of them, have a substantial negative impact on patients and their families, as well as on workers and employers.
In summer 2008, Leana became founding director of the University of Pittsburgh’s Center for Health and Care Work. A collaboration of the Katz School and the School of Medicine, the center conducts research to inform decision making about workforce policy and practice for direct-care workers, defined as “primary providers of paid long-term care in settings such as nursing homes, residential care facilities, and private residences.” The U.S. Bureau of Health Professions estimates the need for at least a million more of these workers in the near term, just to care for the growing elderly population.
One of the key goals of Pitt’s Center for Health and Care Work is to improve the quality, size, and stability of the direct-care workforce. This workforce is central in many of today’s crucial economic and social debates, such as national economic competitiveness, shared prosperity, the welfare of the working poor, and our values regarding how to care for the most fragile in our society.
Leana’s research approach is to decipher what exactly is happening in these jobs and workplace settings by combining the stories of individual workers into a mosaic that illuminates fundamental aspects of the work. “I try to make the invisible visible,” she says about her role as a researcher and director of the center. She tells workers’ stories not just through individual narratives but also through the aggregate numbers.
“If we see the same problems arising, not just in one facility, but across hundreds of sites and thousands of employees, then maybe—as a nation—we’ll pay attention and invest our time and energy on solving the problems.”
In direct-care work, says Leana, there are so many problems that people and organizations often find it difficult to know where to begin. To understand the experiences of the 1.4 million CNAs working in hospitals, residences, and nursing homes nationwide, she teamed up with Jules Rosen, a Pitt professor of medicine who codirects the center. He is an expert in long-term care of the elderly and is chief of geriatric psychiatry services at the University of Pittsburgh Medical Center. He’s still very much an on-the-ground player, having made rounds in nursing homes three days a week for the past 15 years.
With the expertise of Leana and Rosen, the center has initiated a first-of-its-kind CNA study, funded by the Pennsylvania Department of Labor and Industry. Through phone interviews and focus groups, the Pitt research team is tracking 1,400 nursing assistants and aides across Pennsylvania over three years. Among the key issues: What motivates some direct-care workers to leave their jobs while others choose to stay? The answers aren’t so simple.
The center’s preliminary findings have produced some unexpected results, recently published in the journal The Gerontologist. Leana and Rosen organized CNA study participants into two groups: the “leavers,” who move on to other jobs, and the “stayers,” who continue working in the same facility. Interestingly, says Leana, the people who stay with their jobs are motivated by a different set of factors than the people who leave—something that surprised researchers.
When those who leave are asked why they quit, money is a factor, but it’s not the factor. The data show that most leave for another CNA job that often pays no more but that improves the worker’s quality of life—better mentoring and training, a more accommodating schedule, more positive staff-to-patient ratios, among other reasons. The main factors for leaving are lack of respect, dissatisfaction with management, conflicts in balancing family and work, and the job’s difficulty.
While those who stay might agree that these factors exist, the “stayers” remain in their jobs for other reasons. The two main factors are personal relationships with patients and a sense of vocation as part of their job. “What we found,” says Leana, “is that people with more stable work histories in this profession were people who, on their own, imbued their jobs with more meaning.”
The stayers feel “called” to the work. They consider themselves to be patient advocates, with a strong sense of obligation to patients and their families. “It’s poignant,” says Leana. “You see minimum wage workers going out and spending their own money buying knick-knacks to spruce up a patient’s room.” So far, the research suggests that this sense of calling may derive from a deeply held
spirituality or religious belief that also tends to be characteristic of stayers.
The insights derived from Leana’s evidence-based research will help policymakers and employers create more effective recruitment and retention strategies. New efforts could appeal to stayers by addressing factors identified as important to them, while other efforts might separately tackle factors that cause leavers to job-hop.
Economists predict that jobs for direct-care workers who provide face-to-face, personal interaction will grow increasingly important in the years to come—they are, after all, the jobs that can never be sent offshore. In fact, CNA and other care-worker occupations may become a key link in the backbone of a new U.S. economy. For that to occur, however, Leana warns that care jobs must be dramatically overhauled, beginning with enhanced pay and benefits to attract and keep a critical core of “caregivers who care.”
In the end, Leana says, we neglect the problems of direct-care workers to our own detriment. Their circumstances raise larger questions about societal values. Why, for instance, is a direct-care worker—who takes care of our elderly parents or the chronically ill—paid far less than, say, a financial advisor, who takes care of our money? On the practical side, too, these occupations hold key lessons about the negative effects of instability in the U.S. workforce.
In the introduction to Relational Wealth: The Advantages of Stability in a Changing Economy (Oxford University Press), Leana and coeditor Denise Rousseau of Carnegie Mellon University make the case that business relationships are a form of wealth, akin to money, equipment, and the skills of workers.Relationships build trust, which is a necessary condition for effective collaboration, say the two scholars. The emergence of the global economy—accompanied by once rare but now common practices like outsourcing, downsizing, and contract-based work—have shifted the employment landscape to a system of shorter-term economic transactions instead of longer-term, trustbuilding relationships that generate social capital, not simply portable human capital.
Leana’s scholarly work seems to ask: What have we lost in this move toward employment-as-transaction, and how might we restore the full value?
Her large-scale field research on the unemployed and working poor has spanned decades and won accolades. Notably, she received the Aspen Institute’s Faculty Pioneer Award for Academic Leadership in 2007-08. The prestigious honor recognizes leading-edge scholarship with a social-impact focus. She’s an award-winning author, and her articles have been featured in, for instance, The Los Angeles Times and The Wall Street Journal.
An undergraduate English literature major, former Texas bartender, and self-described “odd duck” among business scholars, she loves working with people well outside her own discipline. “One of the things I really like about my work is being able to learn from so many smart people,” Leana has said in discussing her career. She routinely works across disciplines and with colleagues internationally. She also teaches graduate students and executives, here and abroad. A few years ago, she developed the Katz School’s MBA Essentials executive program, and she directs the UPMC-Katz Physician Leadership Program. “I’ve learned so much by partnering with people whose background and academic training are different from mine,” she says.
That experience includes not only her colleagues and students, but also the people she observes in her work—bankers, mill workers, teachers, managers, and health care aides, among others.
The study of CNAs by Leana and colleagues is now in its third and final year of data collection, with much in-depth analysis yet to come. As center researchers complete their findings and publish more insights into these issues, they hope to develop better solutions for a stronger direct-care workforce.
Moving forward, she says, it’s up to each of us to start placing more value on the care part of health care. But first we must be able to see it. So, Leana will continue in her research to make the invisible visible.