Issues of recruitment and retention related to the direct support staff and how these issues affect the lives of people with developmental disabilities were investigated. Major findings included the following: (a) High direct support staff turnover and vacancy rates have negative consequences for many people who receive supports. (b) Direct support staff provide a vast array of services and have numerous job titles and job descriptions. (c) Direct support staff are inadequately compensated and often have to work more than one job. (d) Turnover rate and recruitment is a serious problem. The need to develop the role of the direct support staff into a valued profession is discussed and considerations for research and practice are provided.
Challenges regarding direct support staff recruitment, compensation, and turnover have been documented since the inception of community supports for people with disabilities (Lakin & Bruininks, 1981; Larson, Lakin, & Hewitt, 2002). These same problems of finding, keeping, and adequately compensating direct support staff continue to plague the community support industry today (ANCOR, 2001; Heneman & Schutt, 2001; Hewitt & Lakin, 2001). Many investigators have argued that the ability to find, train, and keep direct support staff is one of the biggest barriers to continued deinstitutionalization and the ability to sustain current community supports (ANCOR, 2001; California State Auditor, 1999; Colorado Department of Human Services, 2000; Hewitt & Lakin, 2001; Hewitt, Larson, & Lakin, 2000; Lakin & Hewitt, 2002).
There are numerous factors that have influenced the direct support workforce. The move to community supports and services and away from institutional services has greatly increased the number of people needed to provide supports to people with disabilities. For example, in June 1977, approximately 40,424 people with developmental disabilities lived in community residential settings (places with 15 or fewer residents), whereas in 2000, the number increased to 289,143 (Prouty & Lakin, 2001).
The United States economy, the labor market, and the demographic makeup of the United States are affecting the recruitment of direct support staff. Persistently low unemployment rates make it difficult for community human service agencies to find people who want to take direct support positions (Colorado, 2000; Heneman & Schutt, 2001; Johnston, 1998) because people looking for jobs have many options. Direct support is a high burnout profession (Jacobson & Ackerman, 1990). Burnout for direct support staff is often caused by the working hours, demands of the job, and lack of respect and societal value for this work. Varied roles and expectations for direct support workers (Taylor, Bradley, & Warren, 1996) have also played a part in staff burnout and training difficulties.
A national study regarding these issues has not been completed since 1992 (using 1990 data) (Braddock & Mitchell, 1992). Although the direct support workforce has not been studied on a national level for more than a decade, the challenge with finding, keeping, and training direct support staff has been identified in several national policy efforts, including the Developmental Disability Act of 2000 (Title III, Section 204) and the New Freedom Initiative (Centers for Medicare and Medicaid Services, 2002). In a few recent state studies, investigators have gathered some data on vacancy rates, turnover, and wages of the direct support workforce. Vacancy rates reported in these studies ranged between 8% and 17% (Hewitt et al., 2000; Johnston, 1998). Average annual turnover rates are reported to range from 45% to 75% (Barry Associates, 1999; Colorado, 2000; Hewitt et al., 2000; Johnston, 1998). Direct support staff wages in the field of developmental disabilities have typically been reported to be low (Braddock & Mitchell, 1992; Larson, Lakin, & Bruininks, 1998) and when compared to other community human services (for individuals who do not have developmental disabilities) are consistently lower (Colorado, 2000; Johnston, 1998). In addition, community direct support wages for staff working with people who have developmental disabilities and live in residential settings have typically been lower than those of staff who work in employment settings and in public sector positions (Colorado, 2000; Johnston, 1998; Larson et al., 1998). In Minnesota the average reported wage for a community residential direct support employee in 2000 was $8.81; in Colorado, the average wage was $8.95 in 1999; and in California, the average was $8.89 in 1998. In addition, many direct support staff members do not have access to benefits, such as paid time off and health care insurance, especially if they work part time.
Braddock and Mitchell (1992) and investigators in the recent state studies have gathered information about the direct support staff workforce from the perspective of administrators and managers. Few attempts have been made to understand issues perceived by the people who actually do this work and from the people who receive direct support. In addition, in previous studies surveys have been used and qualitative data have rarely been included in the analyses. The need to understand these important direct support workforce issues and how they affect people's lives is essential to finding solutions. Unfortunately, previous studies conducted on this issue have not provided insight into how these workforce challenges affect the lives of people who receive supports. The present study was designed to provide insight into the role of direct support staff from the perspective of the people who do this work. In this study we build upon previously conducted survey research by seeking qualitative data through focus groups. The study also provides greater depth on how wage and benefit issues affect the lives of the direct support staff, as well as the people who receive supports. Therefore, our purpose in this study was to provide information about how finding and keeping qualified direct support staff affects the lives of the people who receive support and to determine the current status of direct support staff in one mid-Atlantic state, including information on wages, retention, and vacancy rates. To do this, we gathered data via focus groups from direct support staff, program administrators, and consumers as well as via mailed surveys from direct support staff and program administrators.
We used multiple sources and method to collect data. Three sources were identified for gathering data: (a) direct support staff, (b) individuals with disabilities who receive support services, and (c) administrators of community service agencies. Direct support staff and administrator focus groups were conducted to gather detailed data concerning the recruitment and turnover rates of direct support staff. In addition, focus groups were conducted to gather data from people who receive services. Finally, mail surveys were used to collect additional data from direct support staff and administrators.
Surveys were developed to gather information about direct support staff workforce issues, employment information, and demographic information. The content of the questionnaires was adapted from those presented in Larson et al.'s (1998) monograph on recruitment and retention of direct support staff. Content validity was estimated by having nine experts in the field review the survey items. Feedback from these experts was used to make minor modifications in the wording of a few of the questionnaire items. The review panel made no other recommendations. In addition, the surveys were field tested with direct support staff and administrators, and minor modifications in the wording of some items were made.
Focus groups were conducted across the state with direct support staff, people who receive services, and administrators. The purpose of these focus groups was to gather detailed information regarding direct support staff recruitment, retention, pay, and benefits as well as the impact of these direct support staff issues on the lives of people who received services. Purposive sampling was used to select focus group participants. Groups of direct support staff, recipients of support services, and administrators were identified to participate in the focus groups by asking agencies that were randomly chosen from the stratified sampling frame to identify participants. In addition, focus group participants were recruited at state-level conferences by project staff.
The number of focus groups conducted was determined by the saturation of themes across groups. When the researchers determined, through coding and analysis of obtained data, that the same themes were being repeated without new themes emerging, no further focus groups were conducted. To ensure trustworthiness of the themes, two members of the research team independently examined and coded the responses and developed themes from each focus group. Then, the researchers compared themes and came to a consensus concerning the emerging themes.
The fourth researcher in this study conducted the focus groups. Interview guides and possible probes and follow-up questions were designed for direct support staff, consumer, and administrator focus groups. The duration of the focus groups was between 1 and 2 hours. Data were collected using a tape recorder and written notes. Audiotapes were transcribed and used for analyses.
Demographic Characteristics of Focus Group Participants
There were 8 direct support staff focus groups with 53 participants, 12 focus groups with 70 participants who were recipients of community supports, and 9 administrator focus groups with 56 participants. In the direct support staff focus groups, the participants were predominantly European American (60%) females (64%) who were married (70%). In the focus groups for people who received community supports, most participants were unmarried (96%) and European American (77%), with equal numbers of males and females. Finally, in the administrator focus groups, the participants were mostly married (64%) European American (64%) females (64%).
Several methods were used to identify employers of direct support staff. First, the advisory committee members for the study were asked to identify all agencies or organizations (e.g., North Carolina Long Term Care Facilities, Community Rehabilitation Programs, North Carolina Directory of Respite Care Providers, and others) that employed direct support staff. In addition, the advisory committee identified direct support staff experts in the state of North Carolina. These identified experts were telephoned and asked to provide a list of employers of direct support staff. A total of 1,092 agencies/organizations were identified as employers of direct support staff throughout the state. To ensure adequate representation from the different regions of the state and type of agencies (e.g., residential, vocational, respite, and multiple service providers), the sample was divided into subpopulations or stratums according to the region and type of agency. Proportional random sampling within each subpopulation was conducted. A total of 372 surveys were mailed to administrators. Two follow-up reminder letters were sent to nonrespondents.
A snowball sampling technique (Schutt, 1999) was used to recruit direct support staff survey participants. Respondents to the administrator survey were asked to distribute surveys to their direct support staff employees. A total of 788 surveys were mailed to the agencies that volunteered to distribute them. No agencies refused to distribute surveys to direct support staff.
Demographic Characteristics of Survey Respondents
One hundred and eighty-one direct support staff persons responded to the survey, a return rate of 23.0%. A summary of the demographic characteristics of survey respondents is reported in Table 1. The average age of direct support staff survey respondents was 37.3 years (standard deviation [SD] = 11.0). Most were female (82%), European American (54%) or African American (39%), and not married (53%). Most direct support staff had a Bachelor's degree (32%) or had attended some college (31%). The average direct support staff respondent had worked 4 years in their current position/job and planned to work 8 more years in their current position/job. About half of the respondents had taken a course in mental retardation. Approximately 15% of these respondents were currently enrolled in vocational/technical school or college, and 37% had attended a conference within the last year.
A total of 108 administrator surveys (29.0%) were returned. The average age of administrator survey respondents was 44.0 years (SD = 9.6). Most administrators were European American (71%) females (56%) with a bachelor's degree or higher (68%). The average administrator respondent had worked 8 years in the current agency and 15 years in various roles supporting individuals with developmental disabilities. Administrators were responsible for managing a variety of services, including vocational (31%), residential (19%), multiple areas (17%), personal assistant (6%), in-house support (4%), and respite (3%). The agencies in which the administrator worked provided services to people with mental retardation/developmental disabilities (95%), physical disabilities (56%), mental illness (75%), traumatic brain injury (74%), blind or visual impairment (58%), and deaf/blind (52%). Fifty-six percent of administrators reported taking a course on mental retardation or a course concerning working with people with disabilities.
Focus Group Data
Several recruitment themes emerged from the direct support staff and administrator focus groups. First, direct support staff reported that the lack of qualified direct support staff created emotional problems for the people they supported as well as leading to a lower job satisfaction for direct support staff. Second, administrators indicated that many new direct support staff were uncomfortable working with individuals who had disabilities. Finally, administrators reported that many qualified individuals declined direct support staff jobs because of the low salary, and qualified direct support staff often leave their job for higher salaries.
Both direct support staff and administrators reported that the turnover rate created problems for consumers and staff. Both groups agreed that the quality of service provided to consumers decreases with higher turnover rates. In addition, the high turnover rate lowered staff moral due to increased workload and increased consumer-to-staff ratio as well as decreased the safety for both consumers and direct support staff. For example, one administrator called the turnover rate “a recipe for disaster,” and another supervisor stated that consumers “lose skills when new staff comes in” due to lack of staff training.
People who receive supports also reported that the high turnover rate created personal problems and made training direct support staff difficult. Consumers reported that they experienced sadness when direct support staff members left their job. They also noted that they needed time to build trust with direct support staff and that the high turnover rate meant having to continuously develop new trusting relationships. The major themes identified by people receiving supports on how turnover affects their lives were as follows:
Changes in the individuals who provide direct services cause me problems
Everyone new who comes in wants things done in a different way
Makes me sad
Takes time to get to know someone and then they are gone
No problem, not much change
Not trusting the new person
Hurt feelings, self-blame
Changes attitudes in the workplace
No warning when they quit
Makes me uncomfortable
Makes me nervous
In addition, focus group participants who were recipients of community support services reported that they tended to blame themselves when a direct support staff member left their job. Concerning training, people who receive services reported that each new direct support staff person wanted things done differently, which often resulted in individuals having to learn things all over again.
Direct support staff job characteristics
Direct support staff survey respondents reported 70 different job titles. Administrator survey respondents reported over 155 different job titles for direct support staff (e.g., activities coordinator, adult development vocational coordinator, careprovider). Table 2 summarizes the direct support staff job characteristics as reported by administrators. Results indicate that the typical direct support staff works for a not-for-profit agency (48%) that serves a variety of individuals with disabilities, including people with MR/DD (95.4%), mental illness (75%), and traumatic brain injury (74.1%). Administrators also reported that over half of the persons with disabilities who are supported by direct support staff require assistance with toileting, bathing, dressing, and walking, and they often have challenging behavior.
The direct support staff participants reported that they provided supports to an average of 17 people with disabilities. Direct support staff work at agencies that provide a variety of supports, including vocational (46%), personal assistance (41%), leisure/recreational (37%), and residential (35.3%). Finally, they work a variety of schedules. Administrators reported that direct support staff worked the day shift (88%), evening shift (64%), weekend (58%), nights (57%), split shift (29%), and call-back (19%).
Job benefits and wages
Table 3 summarizes direct support staff benefits and Table 4 shows wage data. The average hourly wage for direct support staff was $9.13 (SD = $1.60). The average hourly entry wage for direct support staff was $7.82 (SD = $1.25, range = $5.00 to $12.00). The average maximum hourly wage was $11.41 (SD = 3.20, range = $5.00 to $19.25). Most of the agencies provided heath insurance (68%). Only about half of the agencies provided other benefits, such as (a) retirement (52%), (b) sick leave (48%), (c) paid vacation time (48%), (d) holiday pay (46%), (e) dental insurance (46%), and (f) personal leave (40%).
Table 5 summarizes direct support staff ability to meet their basic living expenses. The majority of them reported that their pay falls below or does not meet their basic living expenses (66%), and 35% had another job at which they worked an average of 23 hours per week. Most of the direct support staff respondents (79%) reported that their salary was the primary source of income for their family, and they supported an average of 1.9 (SD =.94) legal dependents.
Turnover rate of direct support staff
Turnover rate for each agency was calculated by taking the total number of direct support staff employed by an agency and dividing by number of direct support staff that left the agency over the preceding 12 months. The turnover rate was then converted to a percentage by multiplying by 100. The mean direct support staff annual turnover rate was 41% (SD = 7.05, range = 0% to 312%. Results from the direct support staff administrators' survey indicated that 43% of them felt that direct support staff turnover was a “considerable” or “very much” a problem, and 23% reported that it was “somewhat” of a problem. Only 23% felt that this turnover was not at all or a little problem.
Recruitment of direct support staff
Seventy percent of the administrator respondents reported having problems hiring new direct support staff. The median cost for advertising was $100.00, and agencies used a variety of recruitment strategies, including newspapers (65%), referrals by current or former employees (32%), internal postings (31%), and employment referral agencies (21%). They indicated that they were either very satisfied (24%), satisfied (27%), or somewhat satisfied (19%) with their most recently hired direct support staff. The primary limitations of recent direct support staff applicants were lack of (a) specific training (51%), (b) experience with people who have disabilities (50%), (c) maturity (46%), (d) experience with job responsibilities (43%), and (e) basic communication skills (26%).
In this study high turnover rates and difficulty in recruiting direct support staff were reported as serious problems for the people who receive services and for provider agencies. The average turnover rate for direct support staff was 41%. Nearly 74% of all agencies reported problems with finding direct support staff. As a result of the high turnover rate and difficulty in recruiting, data from the focus groups indicated that consumers suffer from inconsistency in supports and services, and direct support staff suffer low morale. Recipients of services reported difficulties with service quality due to staff turnover and recruitment. These staffing issues negatively affect people's lives. Consumers reported adverse effects, such as a lack of trust between themselves and direct support staff, sadness when people leave their jobs, and self-blame with respect to why direct support staff leave their jobs. In addition, consumers reported that their lives and routines are disrupted when direct support staff come and go from their positions. It is important that service providers, advocates, and policymakers recognize that direct support staff workforce issues, such as vacancies and high turnover, affect quality of services as well as people's lives. Efforts to reduce turnover and increase the number of qualified candidates who might consider direct support staff careers are essential. One step in the effort is to codify the role of direct support staff in our communities, schools, and in the lives of people with developmental disabilities who receive support services.
The findings of this study also suggest that direct support staff in one mid-Atlantic state are not paid enough to meet their living expenses and that many (35%) must work additional jobs simply to pay their bills. The average annual salary of a direct support staff is $18,990. Direct support staff reported that low wages was one of the reasons that coworkers left their jobs and that this turnover negatively affected the people who received services. Further, although 68% of direct support staff included in this study received health care benefits, only about half received other benefits, such as paid vacation time, sick leave, holiday pay, retirement, or dental insurance. Results also indicate that direct support staff work all hours of the day and are usually the primary source of income for their family (79%). Other researchers have also identified inadequate pay and benefits as a primary reason for increased turnover and burnout (Bachelder & Braddock, 1994; Braddock & Mitchell, 1992; Larson et al., 2002). It appears that increased wages and access to adequate benefit packages will be needed in order to reduce direct support staff burnout and annual turnover rates and their negative effect on the lives of people who receive services.
Direct support staff provide a vast array of services, in varied settings to people with varying needs, thus making a single job description difficult. These staff members provide different types of services (e.g., vocational, residential, respite) in different types of settings (e.g., community-based, facility-based, in-home), under different conditions (e.g., individual, group), to multiple customers (e.g., people with developmental disabilities, mental illness, or physical disabilities). In this study 155 different job titles for direct support staff were identified. This lack of consistency in what direct support staff are called is perhaps one indicator of why it is difficult to recruit new people into direct support positions. If individuals who are looking for jobs do not know what the “profession” is, they are less likely to consider employment in that particular position. Efforts to identify a professional role with fewer titles may be useful in bringing professional identity and role clarification to direct support services.
In addition to increased pay and benefits and greater role clarification, other efforts must be made to bring value to the profession. Currently, there are no preservice educational or training requirements for direct support staffs. Although most states do require specific orientation or in-service training (e.g., blood borne pathogens, fire safety, emergency procedures, rights), some states do not require any training. Developing systematic statewide credentialing and other preservice programs will likely assist in creating career paths, professional identity, and increased wages as it has in other industries, such as childcare, substance abuse, and psychosocial rehabilitation.
Creating preservice and credentialing programs may also serve as a mechanism to increase direct support staff wages by offering incentives to direct support staff to further their education and increase their skills. Although this profession is often considered one that includes low skilled and low paid workers (Barry Associates, 1999; Bureau of Labor, 1999; Cohen, 2000; Hewitt & Lakin, 2001), it is important to recognize that although many direct support staff members do not have postsecondary educational training, many do have this additional training. In the present study as many as 45% of direct support staff had a postsecondary educational degree, and an additional 31% had attended some college. Other studies have suggested similar findings (Hewitt & Lakin, 2001; Hewitt et al., 2000; Larson et al., 1998). When seeking support from legislative bodies and policymakers for increases in direct support staff wages, it will be important to focus on the educational levels of many of the direct support staff who work in this industry. Efforts must be made to move beyond the “myth” that the direct support staff is a secondary labor market.
This research has several limitations. First, the sample sizes for the administrators (N = 108) and direct support staff (N = 181) surveys were small, which could result in a larger than desired sampling error. Second, results of the surveys could also contain sampling bias because of the limited knowledge of the target population of direct support staff. In other words, some groups may be overrepresented and other groups underrepresented in the survey results. Third, results could not be reported by type of service provided (i.e., vocational, residential) because most of the respondents provided multiple services. Of the 108 responding facilities, 88 were multiservice agencies. Because of the high number of such agencies, we did not attempt to analyze the data by type of service provided.
In conclusion, finding and keeping qualified direct support staff are critical challenges facing the field of developmental disabilities. Results of the present study suggest that these challenges have serious negative consequences in the lives of people who receive community supports. It also suggests that they are critical problems for direct support personnel and administrators. Efforts to find systematic solutions to direct support staff turnover and high vacancies are essential. Enhanced role clarity and professional identity, increased wages, and improved access to benefits are among the possible solutions.
NOTE: This project was funded at 25% by UNC Charlotte and at 75% by the North Carolina Council on Developmental Disabilities and the funds it receives through P.L. 104-183, the Developmental Disabilities Assistance and Bill of Rights Act of 1996. The authors thank Charlie Lakin for his helpful feedback on our manuscript.
Authors: David W. Test, PhD ( firstname.lastname@example.org), Claudia Flowers, PhD, and Jill Solow, MEd, Special Education Program, The University of North Carolina at Charlotte, 9201 University City Blvd., Charlotte, NC, 28223. Amy Hewitt, PhD, Research Associate, The University of Minnesota, Institute on Community Integration, 107 Pt H, 150 Pillsbury Dr., SE, Minneapolis, MN 55455