WHAT SMALL BUSINESSES AND SMALL HOSPITALS SHOULD KNOW ABOUT EMPLOYEE RETENTION Jim Kerner, Athens State

University Laura Lynn Kerner, Athens State University Robert D. Gulbro, Athens State University Linda Shonesy, Athens State University Abstract Organizations that fail to maintain an aggressive and effective employee retention program will allow their talent to walk out of their doors taking with them training and job experience that will benefit the gaining organization. Literature has shown that there are identifiable factors that cause employees to leave their employers and seek opportunity elsewhere. Once healthcare-related business and medical practice managers are aware of these factors, a set of initiatives can be implemented to avoid this loss of human capital. The purpose of this paper is to explore what other business entities have experienced regarding employee retention issues and identify those intrinsic factors that affect employee turnover. Taking Responsibility for Human Resource Management Some small hospital administrators, business owners, and medical practice managers glibly abdicate strategic human resource initiatives by unwittingly accepting employee turnover of physicians, nurses, and support staff, as a necessary and inevitable cost of doing business (Waldman, Kelly, Arora, & Smith, 2004, p. 2). However, they are failing to see the larger impact on their businesses; these effects are real and pervasive. Maintaining appropriate staffing levels is a significant component of productivity. A cogent argument can be made that there is a direct correlation between staffing levels and the ability for businesses to attain their goals and objectives thereby impacting organizational effectiveness as well as primary mission attainment. The development of an employee retention plan should be a crucial component of any small business or medical practice. The effects of employee turnover negatively impact customer service, work production standards, and profitability. Recruiting and retaining skilled workers will become increasing harder due to the near retirement of a large segment of the current workforce referred to as the baby-boomers. Employer competition for workers will become increasingly aggressive as the workforce shrinks. Employee retention thus becomes increasingly more important each year. Background and Significance of the Problem At the risk of doomsday prophesy, there is and will be a severe labor shortage that will impact and challenge most businesses. Labor supply continues to be tight and indications are that this trend will persist. The American Society for Training and Development (2003) stated:

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The labor-supply shortage that accompanied the economic boom of the late 1990s gave the nations employers a taste of whats to come in the 21st century. As the growth of the U.S. population and workforce slows and diversifies in the years ahead, and as the global economy places an ever-growing premium on workers knowledge and skills, organizations will have a choice to make. Either devote the necessary time and resources to building and maintaining a pool of talented, knowledgeable workers, or watch from the sidelines while others demonstrate the connection between strategic human capital development and organizational success (p. 11). The fact that the United States had experienced a lower birth rate in the late nineties equates to fewer future workers (Booth News, 2003), further compounding the workforce shortage problem. In addition, the baby-boomers are facing retirement, which will lead to an even smaller workforce pool. Cascardo (2002) reports: In fact, the dearth of healthcare workers qualified to fill jobs in hospitals, medical offices, and other settings recently prompted AHA President Dick Davidson to call the shortage an impending public health crisis that will test the healthcare system in the coming decade (Introduction, para 3). The American College of Healthcare Executives surveyed 984 hospital CEOs in November of 2002 to ascertain their most pressing concerns. Seventy-one percent said that personnel shortages were their number one concern (American College of Healthcare Executives, 2003). According to a writer for Modern Healthcare, contrasts the recent Y2K scare, a mere blip on the computer screen, against the impending healthcare worker shortage that will hit in 2011: That's the year an already chronic shortage of front-line healthcare workers is set to become an epidemic. I very much doubt we will be looking back on 2011 with the same nonchalance as we do the millennium bug (Sloane, 2003, p. 1). The importance of the workforce shortage cannot be overstated as it is just one of the dynamics affecting employee retention. Other dynamics may include the demographic make-up of the workforce, able-bodied available workers present, skill level of the workers, current unemployment rate, economic growth, and organizational leaderships ability to recognize the need and plan for retention strategies. The solution may well be a multifaceted, comprehensive, and may require collaborative partnerships between government, academia, and industry; but more research is required to determine this. Economic Dynamics External to the Organization One of the ongoing challenges of managing the human resources component in any business is ensuring adequate staffing levels. With fewer people entering the workforce, it is imperative that leaders employ effective employee retention strategies. It is becoming clear some businesses are recognizing that strategies that worked yesterday will not be as effective in todays or tomorrows workforce environment. One reason is fundamental to demographics- a significant segment of the workforce known as the babyboomers face retirement. But this seems to be just half of the story, as replacements for the baby-boomers do not appear to be coming, in which case the shortage of workers will become worse. According to the American Hospital Associations (AHA) Strategic

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Policy Planning Committee This extra large cohort of workers [baby-boomers] is followed by the baby bust generation, a relatively small pool of workers (2001, section 4, para.1). This is strong evidence that suggests a workforce shortage is going to be here for a while and that businesses must take employee retention serious if they want to meet the challenge of finding workers. In addition, Since 60 % of boomers are planning early retirement, the skilled-labor gap will begin building to a crisis by 2005 even if the economic slowdown continues (Whithers, 2001, para. 5). While it is true that the healthcare industry continues to suffer from a lack of qualified workers, especially registered nurses (Cascardo, 2002, section 1, para. 1), it is also true shortages are not limited to any one occupation. Though the nursing shortage has received much attention, hospitals also face a decreasing applicant pool of pharmacists, technicians, technologists, therapists, housekeepers, food service workers, information service specialists, medical record coders and others (American Hospital Association, 2001, para. 5). The labor-supply shortage makes employee retention a strategic initiative for small hospitals and medical practices. According to the American College of Healthcare Executives (ACHE) (2002), the current healthcare industry is plagued with staff shortages, higher patient volumes, and dwindling profit margins. In addition, the healthcare industry must understand that workforce retention is a major factor in an organizations success (p. 1). Visionary business leaders recognize that employee retention is a serious issue in todays healthcare related industry. One such leader suggests a broader and more permanent fix for combating turnover by making retention a part of the organizational culture. Barbara Blakeney, president of the American Nurses Association states, You have to create a culture of retention (Cadrain, 2002, sec. 4, para. 2). Those in fiduciary positions also advocate employee retention for their organizations. Peg Neuhauser, PhD and noted sociological expert is cited in an article in the Trustee Bulletin (July/August, 2003, p. 6). She advises other trustees to Keep in mind to accomplish a high [employee] retention impact. . . (p. 7). A survey (Intention to Stay or Leave Employer) was conducted, which asked employees "How long do you plan to continue your career with _______________?" A total of 274 people responded. These results are among the 239 respondents who said they currently are employed and are as follows; (a) 16% indicated less than a year, (b) 17% indicated one to two years, (c) 15% indicated two to five years, (d) 35% indicated more than five years, and (e) 16% did not know (The Business Research Lab, 2003, para. 1). Taking note of the categories of one to two years (17%) and less than a year (16%), and combining the two categories yields a 33% turn over of employees who intend to remain less than two years. Thirty-three percent is a significant number and a business could work toward reducing this percentage through an effective retention program. Turnover Causation Employees leave jobs for various reasons and finding remedies suitable to the organization may be a daunting task. Even if the remedies are employed it is no guarantee that the employees will be happy and stationary, but management must try. Studies, such as the one involving members of the Development Dimensions International Benchmark

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Group, have indicated that there is a correlation between employee job satisfaction and intent to voluntarily terminate (Bernthal & Wellins, 2001). John Gering (2002), of the management-consulting firm, CG & A, expresses employee dissatisfaction this way; The gap between the words and the behaviors of the company is the measure of employee dissatisfaction (p. 5). According to Business Research Lab (2003), a Delaware based Limited Liability Company specializing in business consulting, In the employee satisfaction studies we have done, we've never found a firm with low employee recognition scores and high employee satisfaction scores (para. 1). While job satisfaction is comprised of several dynamics, the common denominator seems to be the role that the supervisor plays. Businesses today are leaner and less hierarchical; this fact has impacted and changed the way that contemporary employees view their immediate supervisors. As a result, supervisors need to change the way they view their employees. "Employees think of their immediate supervisors as the primary representatives of their employers' missions, policies, systems, and practices" according to Bruce Tulgan, cofounder of RainmakerThinkingInc. With this significant shift of organizational representation, it becomes crucial for immediate supervisors to build trusting and collaborative relationships with staff. "The day-to-day communication between supervisory managers and direct reports has more impact than any other single factor on employee productivity, quality, morale, and retention" (Fast Company, 2003. p. 1). The Business Research Lab used their online survey (sampling and population undisclosed) to determine if the respondents had ever quit their job because of their supervisor. The online poll (Ever Quit a Job Because of Supervisor?) ended March 22, 2000. Results show that 58% had quit due to supervision. The relationship that supervisors have with subordinates has never been more important. Let's be clear about something. People don't leave organizations. They leave managers who continually fail them in some important respect (Catlette & Hadden, 2000, sec. 4, para. 2). Employees want to be treated with respect, feel like they have a voice, and that their opinion matters. They resent feeling like a commodity. The president of Society for Human Resource Management (SHRM) of Greater Tucson, Chapter #181, states; Human Resource representatives must treat human capital with the same respect and interest that the finance department shows the company's money. Just as the finance team cracks the whip on departments or company leaders who don't allocate funds properly or who squander valuable resources, the HR team must come down hard on managers who consistently drive away good talent or who inadequately prepare new recruits for the job ahead. Talent is on loan to managers. They don't have the right to abuse that investment (Nuzzo, 2003 p. 2). It is during these times of skilled labor shortages that managers should be responsible for retaining their top people. HR experts such as San Francisco State Universitys John Sullivan, say those same managers are probably to blame for their own worries (Dobbs, 2001, para. 1). Many of our business leaders fail to understand how important it is to develop a trusting relationship with the talent in their organizations. In fact, in many cases, employees are afraid to voice their opinions about organizational issues. According to the founder and president of Brendler Associates, Inc., 70 percent of people in organiztions hesitate to speak up for fear of repercussion (Brendler, n.d., para. 2).

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Claims such as these indicate that employees are distrusting and that it is the responsibility of leadership to correct this condition. If it isnt corrected, then in the perception of the employee, conditions deteriorate and the motivation to leave increases. In his writing People Dont Leave Jobs, They Leave Their Bosses, Kelloway (2004) suggests that money is not as an important factor as is leadership. Leadership, not salary, emerges as a cause of a great deal of turnover (p. 2). Cox (2004) & Associates, a healthcare-consulting firm based in Brentwood, Tennessee, has conducted nearly 300 healthcare organizations. Their findings support that managerial relationships are key to turnover. In most surveys about retention in nursing, the relationship with the manager is among the top three reasons why nurses leave their jobs (p. 1). Stress is another reason for employee turnover and its impact is not going unnoticed. The National Institute on Occupational Safety and Health (1999) has warned that occupational stress is emerging as a principal social and occupational health concern. Job stress exerts a profound toll in terms of employee health and business economics (p. 1). According to research conducted throughout the 1990s by insurance companies, it was determined that 40% of job turnover is due to stress (National Institute for Occupational Safety and Health, 1999). Wolfe (2003) reports in Business 2 Business that USA Today released results of a survey in February that revealed the top four causes of stress were as follows; demands of the job (54%), co-workers (20%), boss (10%), and layoff fears (8%). Three recent studies indicate that employees view work as a source of stress. Twenty-five percent of employees view their jobs as the number one stressor in their lives in a study by Northwestern National Life; 75 % of employees believe the worker has more on-the-job stress than a generation ago in a study by Prinston Survey Research Associates; and Problems at work are more strongly associated with health complaints than are any other life stressor- more so than even financial problems or family issues in a study by St. Paul Fire and Marine Insurance Company (National Institute for Occupational Safety and Health, 1999, pp.3--4). Stress levels for small business and medical practice employees continue to increase with each new day. Doing more with less seems to be the mantra of modern business cultures, and it is no different in modern health care. Although small businesses do not have shareholders in the traditional sense, patients and their families are the primary stakeholders. They are demanding in terms of patient care and expect a return on their investment. The level of expectancy by patients and their families continues to increase as they become more informed as consumers. They are keenly aware that they can take their patronage to the business down the street. In addition, the reimbursement dollar is stretched, additional workloads are put on employees, and staff positions are eliminated. An increased workload presents unique burdens on staff in that they are often limited to an eight-hour workday and without overtime the only recourse would be to work harder and faster. This type of stress is referred to as Quantitative Overload (Cummings and Worley, 1997, p. 431). Turnover Costs

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According to Waldman, et al., 2004, there are direct or actual costs and indirect costs associated with employee turnover. There are many formulas to calculate turnover costs with some using an estimated or straight percentage of salaries plus benefits. Others are more elaborate taking into account additional factors. A Michigan Health System uses the following formula: average staff salary times 50 % replacement costs for 40 days (length of time to fill position) plus the value of a supervisors time to conduct interview plus average staff salary times 50 % for the first three months (to account for training and reduced productivity) plus 25 % of lead persons (trainer) salary for three months to equal total cost of turnover (Workforce Management, 2005). The cost is even higher for the upper ranks in the organization. For executives, turnover costs can be from three to five times the annual salary plus benefits (KeepEmployees Inc., 2004). There are indirect costs associated with turnover with regard to hiring new staff and include advertising for the position, administrative costs associated with processing applications, conducting interviews and drug screening, performing pre-employment background checks as well as conducting training. Less obvious costs include the negative impacts on businesses such as the loss of experienced trained staff thereby causing a decrease in productivity and customer service and the loss of the related revenues. These present additional challenges to healthcare providers who struggle to ensure a smooth, eventless, patient-care continuum. High rates of turnover also sends out a message to other remaining employees indicating that leaving the organization is more acceptable than to seek opportunity within the present organization. It is therefore imperative that business managers determine the causes of employee turnover in their environment and be proactive in retaining this valuable organizational human asset. Businesses also feel the negative impact from the mistrust that 70% of employees feel in todays organizations. Employees are hesitant about sharing their knowledge for fear of reprisal from upper management (Brendler, n.d.). These lost insights, that may have solved operational issues or problems with customer service, never reach the decision makers. The organization is robbed of vital information (intellectual capital) that may very well have had a positive impact on the way the organizational does business. This type of disengagement may cause employees to become apathetic and begin to detach themselves from the day-to-day routine forming instead a kind of myopia where they tend to view only their job and their specific responsibilities. Other costs, depending on the position, may also include placement charges by outside recruiters, relocation charges to include temporary lodging, travel and meals. Retention Strategies Hiring the right people to begin with seems to be a winning strategy. According to Jim Collins, the author of From Good to Great, By recruiting the best possible personnel, a firm can improve its returns on each payroll dollar. In addition, The executives who ignited the transformations from good to great did not first figure out where to drive the bus and then get people to take it there. No, they first got the right people on the bus (and the wrong people off the bus) and then figured out where to drive it (Longenecker, Moore, Petty, & Palich, 2006, p. 421). Conducting pre-employment screening contributes greatly to choosing the right employee for the job. This should be an integral part of a

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retention strategy. Several pre-screening benchmarks include: cultural fit, family stability, good work ethic, solid employment record, and good references. Study results show that some employers are not relying on historical data alone, but are looking to see if the candidates match up to what the company has to offer to include energy level, forthright responses, carriage of the person, personal chemistry, location of residence, and evidence that he or she has made the major decisions in life. Job shadowing is another technique that is producing marked results in a small mid-western hospital. St Francis Medical Center has adopted a job previewing technique that allows perspective employees to try out for the job by shadowing a department worker throughout the day. This provides a realistic experience that will help the prospect to accept or decline the position. The benefits are real; the number of job applicants has increased, which provides the 189-bed hospital with a greater number of potential employees to choose from. Also, if the prospect is hired, chances are they will stay in the position because they came in with eyes wide open. The data that supports this show that the turnover percentage dropped from 20.6 in 2000 to 15.7 in 2003. This strategy proved successful after staffing shortages resulted in some patients being diverted to other hospitals (Huff, 2005, p. 1). In a project where Izzo Consulting (2001) reviewed several large retention studies, which included studies by the Gartner Group, Fortune, and Wyatt International, they identified the lists of key reasons employees left their employers. The following are listed in order beginning with the number one reason; (1) lack of recognition, (2) inequities in salary, (3) long-term sense of purpose and mission are missing, and (4) insufficient opportunities for professional and career development (promises may not match reality) (p. 1). The review was conducted in July 2000. Salary is important, but seldom the sole reason. Salary offers of 20 % or higher are hard to beat; being within 10-15 % may be adequate for retention (p. 1). Aubrey Daniels, Ph.D, founder and CEO of Aubrey C. Daniels and Associates, confirm the Izzo findings (Daniels, 2003, para. 2). Employee Recognition is perhaps one of the easiest of the problems to resolve. It begins with a simple thank you (Herman, 2000). Recognition can be as simple as expressing to the employee that he or she has performed well on a particular task or as complicated and expensive as awarding all expense paid trips to deserving employees. Recognition finds its roots in the work of the humanistic psychologist, Abraham Maslow. He proposed that within every human being there is a hierarchy of five needs: physiological needs, safety needs, social needs, esteem needs, and self-actualization needs (Robbins & Coulter, 1999, p. 50). Esteem needs are those factors such as self-respect, autonomy, achievement, status, recognition, and attention. Although Maslow categorizes esteem as a low order need, it is still significant and contributory to the persons self-perception and over all sense of well-being. Although recognition and incentives tied to it are not always free of expense, any expenditure seems well worth the investment in terms of employee satisfaction and its impact on employee decisions to remain with their employer.
Recent research indicates that retention should begin on the employees first day of work. The process of assimilating newly hired staff into the organizational culture is important. This period is particularly critical because the employee is still evaluating the employers for personal fit. In a study conducted by the Carlson School of Management, University of Minnesota it was found that a newcomers initial attitude strongly

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influences subsequent attitudes (2003, p. 4).

Other strategies include the use of compensation plans as a crucial component to an employee retention strategy. Innovative thinking put to trial and run basis seem to reveal interesting results. A growing number of compensation plans are now focused on cutting costs while retaining valuable staff. This is an abrupt change from just last year when most human resource specialists were working hard to attract talent and keep pace with soaring pay levels (IOMA, 2002, p.1). IOMA also conducted a survey where small organizations (up to 500 employees), mid size organizations (from 500 to 1,499 employees), and large organizations (1,500 or more employees) were surveyed. Respondents were asked to answer specific questions on those methods used to cut costs and improve retention. Types of organizations surveyed included wholesale and retail companies, trade companies, educational institutions, financial and banking firms, business services, manufacturing companies, nonprofit entities, technology companies, and insurance firms. Results showed that the most popular method was to reduce or eliminate merit pay increases according to 22 % of the respondents for all organizations combined. Some employers are going further and tightening guidelines for merit increases in addition to reductions for amounts paid. Instituting pay for performance is the next most popular method to reduce compensation costs with 19.4 % of respondents citing this option. Changing the base pay or bonus mix was next at 17.5 %. Benchmarking or establishing salary levels was favored by 15.5 % of respondents and viewed this as a long-term strategy. Other strategies were discussed and most were industry specific (IOMA). One strategy that most any business can employ is becoming an employer of choice. In more progressive organizations where it is realized that in order to maintain staffing levels, it is necessary to become an organization where staff want to work. Fitz-enz (2000) suggests the following steps: a. Treat employees fairly, b. Provide interesting and challenging work, c. Make the work place an exciting and fun place to come to every day, d. Provide opportunities for employee growth, and e. Honestly believe that people are value-adding assets to the organization (p. 2, para. 4). The Gallup Organization conducted research to determine the impact that employee satisfaction had on business outcomes. Their findings showed that when employees have above average attitudes toward their work that there is 38 % higher customer satisfaction scores, 22 % higher productivity, and 27 % higher profits (Employee Retention Headquarters, 2001). Perhaps an element of employee satisfaction is the concept of employee engagement. Burke Inc., a research and consulting firm, has identified the elements of employee engagement and how they impact employee performance and ultimately the impact on profitability, loyalty to the organizations customer base, and retention. The six elements that comprise the Employee Engagement Index or EEI are (a) company, (b) manager, (c) work group, (d) the job, (e) career/profession, and (f) customer. The model suggests that where there are high levels of satisfaction in the relationships between the six elements and the employee, employee engagement will be high. Based on extensive research, Burke Inc. indicates that engaged employees are more likely to stay with the company, be an advocate for the company and its products and services, and contribute to the bottomline business success. There is a significant link between employee engagement, - 85 -

customer loyalty, and profitability (2005, p. 1). They are not alone in this theory. The Gallup Organization (2005), with a respondent base of 3.82 million employees, has been involved in research that proved that engaged employees are more profitable, . . . and more likely to withstand temptations to leave (p. 1). In a 2004 study by the Performance Assessment Network, results showed that 31 % of the respondees were unengaged and halfway out the door. . . . High costs of turnover can often be traced to a lack of engagement by employees (Shuit, 2005, p. 1). Some businesses may try to resolve staffing shortages by using quasi remedies such as placing the emphasis on recruiting. However, employing an effective employee retention program is best. Your best recruiting is retaining your current employees according to Regina Rathman, employment coordinator (Huff, 2005, p. 2). In a report by Modern Healthcare, they state that Although recruitment and training of new workers are critical, retaining them is even more important. . . (Sloane, 2003, p. 1). The best companies know that retention is what counts. . . In the final analysis, attracting good talent is insufficient, says Jim Wall, national managing partner of human resources for Deloitte & Touch, LLC. What really counts is retaining people, he says (Solomon, 2000, p. 4). Understanding, identifying, and addressing causes of employee turnover are components of an employee retention strategy. Resolving these issues positively impacts the morale among the staff of an organization. This is essential, especially in todays market place, where proactive leaders see that employees want more than just a job- they want fulfillment, sense of accomplishment, and social interaction. In short, they want a psychological paycheck. As a result, the business will realize greater employee satisfaction which will lead to higher productivity, greater customer satisfaction, and the leader will find it easier to reach business goals and objectives. In the short term, however, hospitals and medical practices must work harder to provide better workplace conditions and to offer employees the flexibility to balance their work and family demands (Cascardo, 2002, sec. 2, p. 3). Strategic human resource planning plays an ever increasingly important role in employee retention. The human resource function in businesses today must acknowledge that the demographics of the workforce have been changing and will continue to change in the years to come. Therefore, it is imperative that hiring practices be adapted accordingly. According to Oss (2004), the ability to recruit a multilingual, culturally sensitive workforce is especially critical to success with an increasingly diverse population, and an organization whose workforce does not reflect the populations diversity will find it more difficult to compete. HR departments will need to focus extensively on diversity, work/life, and compensation arrangements in the coming years (p. 22). Small firms are at a disadvantage in attracting and keeping good employees. They need to make use of every strategy possible to avoid HR issues and problems. The biggest problem has been shown to be retaining good employees. The best employees contribute the most to a small firm but also can easily find

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other jobs. Maintaining a satisfied work force may make for a more efficient and effective organization (Thomas, Franklin, and Rainsford, (2005). References American College of Healthcare Executives. (2002). Top issues confronting hospitals. ACHE In the News, January 8, 2003. Retrieved 11/19/2004 from http://www.ache.org/Pubs/Releases/090302_workforce_advisory.cfm American College of Healthcare Executives. (2003). Regaining our workforce, regaining our potential. ACHE In the News, September 3, 2002. Retrieved 11/19/2004 from http://www.ache.org/Pubs/Releases/010802_ceo_survey.cfm American Hospital Association. (2001). Workforce supply for hospitals and health systems issues and recommendations. News Release, 1/31/01. Retrieved 1/16/2005 from http://www.hospitalconnect.com/aha/key_issues/ workforce/ commission/ workforceshortB0131.html American Society for Training and Development. (2003). The human capital challenge. A Whitepaper by the ASTD Public Policy Council. Retrieved 3/13/2005 from http://www.astd.org/NR/rdonlyres/ 2E4BC9A4-F1A6-457B-A4183DBCF9A89806/0/HCWPcolor.pdf
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