Retaining counseling staff at substance abuse treatment centers: effects of management practices

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1 Journal of Substance Abuse Treatment 24 (2003) Regular article Retaining counseling staff at substance abuse treatment centers: effects of management practices Hannah K. Knudsen, M.A. a, *, J. Aaron Johnson, Ph.D. a, Paul M. Roman, Ph.D. a,b a Center for Research on Behavioral Health and Human Services Delivery, The University of Georgia, 101 Barrow Hall, Athens, GA , USA b Department of Sociology, The University of Georgia, 119 Baldwin Hall, Athens, GA , USA Received 19 July 2002; received in revised form 25 October 2002; accepted 18 November 2002 Abstract The turbulence created by the emergence of managed care has increased the importance of staff retention for substance abuse treatment centers. This study examines the relationships between management practices, organizational commitment, and turnover intention among substance abuse treatment counselors. Counselors from 345 randomly selected privately funded treatment centers were surveyed about management practices, organizational commitment, and turnover intention. Structural equation model estimates indicate significant associations between these variables. The effects of performance-based rewards and support for creativity, two measures of management practices, on turnover intention are mediated by organizational commitment. Job autonomy has a direct effect on turnover intention. Treatment center administrators may improve staff retention by systematic attention to these factors shown to enhance organizational commitment and reduce counselors intentions to quit. Such steps may include increasing counselor autonomy, providing rewards for strong job performance, and establishing a work environment that supports creativity and innovation. D 2003 Elsevier Inc. All rights reserved. Keywords: Turnover intention; Management practices; Organizational commitment; Counselors; Substance abuse treatment centers 1. Introduction In recent decades, substance abuse treatment providers have been drastically affected by controls imposed by managed care. Concurrently with the rise of managed care in substance abuse treatment during the early 1990s, nearly one third of privately funded organizations that offer alcoholism treatment services closed (Blum, Roman, & Shane, 1996). Though the rate of closures has since slowed, a more recent study found that nearly 15% of substance abuse treatment centers closed between 1995 and 1999 (Johnson & Roman, 2002). Those addiction treatment centers that remain open must find ways to contain the costs of treatment while providing quality services that are attractive to consumers (Mechanic & McAlpine, 1999). Associated with the managed care environment is the instability created by turnover among centers counseling staff (Hser, 1995). This instability may * Corresponding author. Tel.: ; fax: address: hknudsen@arches.uga.edu (H.K. Knudsen). further threaten the ability of centers to meet the demands that are associated with organizational survival. This research models the relationship between treatment center management practices and the retention of counseling staff. The focus is upon how management decisions regarding the design of counselors jobs are related to the intentions of counselors to quit their jobs. Using data from 1074 counselors who work in 345 randomly selected, privately funded treatment centers, this research evaluates the direct and indirect effects of three measures of management practices, namely job autonomy, performance-based rewards, and support for creativity, on turnover intention. Studying turnover intention is important for those concerned with reducing the rate at which employees actually quit their jobs (Farkas & Tetrick, 1989; Griffeth, Hom, & Gaertner, 2000). Measuring intention to quit rather than retrospectively examining quitters has the advantage of tapping the here and now factors that determine this critical decision. High turnover, with its monetary and nonmonetary consequences, represents a threat to the effectiveness of nearly any organization (Bannister & Griffeth, 1986; Vandenberg & Nelson, 1999). Monetary consequences /03/$ see front matter D 2003 Elsevier Inc. All rights reserved. doi:10:1016/s (02)

2 130 H.K. Knudsen et al. / Journal of Substance Abuse Treatment 24 (2003) include costs associated with recruiting, hiring, and training new counseling staff. In addition, there are non-monetary outcomes associated with high turnover such as inconsistency and discontinuity in service delivery that may undermine efforts to provide high quality care (Lum, Kervin, Clark, Reid, & Sirola, 1998). Considering turnover intention is particularly important for substance abuse treatment organizations. Substantial turnover rates among counselors suggest that this is an important management issue for administrators (Hser, 1995; Laundergan, Flynn, & Gaboury, 1986). Our own data from the National Treatment Center Study (described in Methods and materials) indicate an average turnover rate of 18.5% among substance abuse treatment counselors. This rate far exceeds the national average of 11% across all occupations and is significantly higher than the average annual turnover rates of teachers (13%) and nurses (12%), occupations traditionally known to have high rates of turnover (Cavanagh, 1989; Ingersoll, 2001). It is important to consider how managerial decisions may reduce and reverse the intentions of addiction counselors to quit. The purpose of this paper is to estimate the associations between management practices, organizational commitment, and turnover intention using survey data from substance abuse counselors Theorizing the predictors of turnover intention Retention of employees is embedded in exchange processes. Within the larger framework of social exchange, the norm of reciprocity suggests that the provision of valued ends generates an obligation for the recipient to reciprocate (Blau, 1964). Applied to substance abuse treatment centers, the norm of reciprocity posits that when management provides a positive work environment for counselors, those counselors will work in ways that are in the interests of the treatment center (DeCotiis & Summers, 1987; Eisenberger, Huntington, Hutchison, & Sowa, 1986; Jamal, 1990; Settoon, Bennett, & Liden, 1996). Counselors who work in a treatment center with a rewarding and supportive environment will be more committed to the treatment center and less likely to intend to quit their jobs. There is some evidence that management practices that result in rewarding work experiences have direct effects on turnover intention. Consistent with the norm of reciprocity, there is evidence that work stressors may be perceived as negative exchanges between management and workers and are thus positively related to turnover intention, while rewarding working conditions reduce workers intentions to quit (Griffeth et al., 2000; Jamal, 1990; Vinokur- Kaplan, Jayaratne, & Chess, 1994). Based on this evidence, it is expected that management practices that create rewarding job characteristics, such as job autonomy, performance-based rewards, and organizational support for creativity, reduce the likelihood that employees intended to quit their jobs. It may appear that good management practices can sharply reduce or even eliminate employee turnover. One of the variables studied in predicting turnover intention is organizational commitment, which refers to an employee s identification with and loyalty towards an organization (Mathieu & Zajac, 1990; Meyer & Allen, 1997; Mowday et al. 1979). Researchers often find that turnover intention and job characteristics are connected via commitment to the organization, such that some of the effects of job characteristics on turnover intention are mediated by commitment (Lease, 1998). In other words, the process underlying the relationship between job characteristics and turnover intention may be such that positive features of work enhance organizational commitment, which in turn reduces intention to quit. Previous research has demonstrated a strong link between organizational commitment and turnover intention, indicating that with increased commitment, the likelihood that an employee intends to quit decreases (Allen & Meyer, 1996; Aryee & Heng, 1990; Cotton & Tuttle, 1986; Farkas & Tetrick, 1989; Hendrix, Robins, Miller, & Summers, 1998; Kim, Price, Mueller, & Watson, 1996; Meyer, Allen, Smith, 1993; Somers, 1995; Somers & Birnbaum, 2000). The decision to quit a job is a complex process, affected by personal, familial, and friendship variables, in addition to local labor market conditions. There may be organizationally-based variables involved as well, but these variables may be difficult to measure or detect, such as personal friendships which disintegrate over time or personal animosities that escalate between employees. Thus, organizational commitment is not the mirror image of turnover intention. What is important is to establish what can and cannot be effectively changed by management. It is unlikely that management can control employees personal desires, family obligations, and the rise or fall of interpersonal relationships among employees. However, it is clear that other dimensions of the organizational environment can be affected by management practices, which in turn may positively impact organizational commitment and reduce turnover intention. The empirical literature on organizational commitment has considered the role of certain job characteristics, such as job autonomy, performance-based rewards, and support for creativity. Previous research supports the theoretical proposition that when jobs are rewarding, employees are more committed to their organizations (Meyer et al., 1993). In particular, job autonomy, or the amount of control that employees have over how they perform their job tasks, has been found to be positively associated with organizational commitment (DeCotiis & Summers, 1987; Dunham, Grube, & Castaneda, 1994; Eby, Freeman, Rush, & Lance, 1999; Kalleberg & Mastekaasa, 1994; Lincoln & Boothe, 1993; Mathieu & Zajac, 1990; Mottaz, 1988; Wallace, 1995). The fairness in how rewards are distributed to employees, particularly for strong job performance, appears to be positively associated with organizational commitment (Wallace, 1995). In addition, the extent to which an organization supports

3 H.K. Knudsen et al. / Journal of Substance Abuse Treatment 24 (2003) creativity and innovation may be positively associated with the commitment levels reported by their employees (Livingstone & Nelson, 1997). However, the distribution of rewards for strong job performance and support for creativity have received less attention in the commitment literature than job autonomy. We hypothesize that rewarding job characteristics will have direct effects on turnover intention and indirect effects through organizational commitment. The purpose of this study is to test this proposition using a survey design. 2. Methods and materials 2.1. Sample The hypothesized model was estimated using data collected during the second wave of the National Treatment Center Study. Since 1995, this longitudinal study has collected data from staff at 450 privately funded substance abuse treatment centers. Initial data collection efforts in centered around on-site interviews with the administrators, clinical directors, and marketing directors. During the second wave of data collection in 1997 and 1998, information was obtained through on-site interviews with the administrators, clinical directors, and marketing directors. Data were collected from over 90% of the centers that participated in the first wave Data collection During the second wave of data collection a mail questionnaire was used to survey the counseling staff at the sampled centers. This research design was approved by the authors human subjects committee of the institutional review board at their university. During the on-site visit, administrators were asked to supply the interviewer with a list of the counselors at their center. About 85% of administrators provided this information. Questionnaires were subsequently mailed to these counselors. In all, 1,942 questionnaires were mailed to counselors from 345 centers. Completed questionnaires with their indications of informed consent were obtained from 1,107 counselors, representing a overall response rate of 57%. This analysis is limited to the 1,074 counselors that provided responses to all of the included measures, which represents a final response rate of 55% Measures The dependent variable of turnover intention was based on three items by Walsh, Ashford, and Hill (1985). These three items asked respondents to rate on a seven-point scale their intentions to quit their jobs. As with the other workrelated variables, a higher score on each item reflects a greater quantity of the construct. The wording of each of these items as well as the other work characteristic variables appear in Table 1. Organizational commitment was considered as an intervening variable and was measured using seven items, adapted from the Organizational Commitment Questionnaire developed by Porter, Steers, Mowday, and Boulian (1974). Organizational commitment reflects the extent of the counselor s loyalty and identification with their treatment center of employment. Table 1 Confirmatory Factor Model Factor Item wording loading Turnover Intention by As soon as I can find a better job, I will leave this center..824 I am actively looking for a job at another center..878 I am seriously thinking about quitting my job..857 Organizational Commitment by I am willing to put in a great deal of effort beyond that.526 normally expected in order to help this center be successful. I really care about the fate of this center..560 I am extremely glad that I chose to work at this center.800 over others I was considering at the time I joined. I speak highly of this center to my friends as a great.883 place to work. I am proud to tell others that I am part of this center..884 I find that my values and this center s values are.839 very similar. For me, this is the best of all possible centers.873 for which to work. Autonomy by I have sufficient authority to fulfill my job responsibilities..862 I have enough freedom over how I do my job..870 I have enough authority to make decisions necessary to.892 provide quality treatment service. Support for Creativity by Our ability to function creatively is respected by the center s management. At this center assistance in developing new ideas is readily available. New ideas can come from anywhere at this center and will be equally well received. Employees at this center are encouraged to develop their own ideas, even when they deviate from those of the center s management. Employees of this center feel encouraged by their superiors to express their opinions and ideas Work Rewards by The amount of recognition I receive when.484 I do a good job is satisfactory. There is a strong link between how well I perform my job.619 and the likelihood of my receiving recognition and praise. There is a strong link between how well I perform my job.725 and the likelihood of my receiving a raise in pay/salary. There is a strong link between how well I perform my job.846 and the likelihood of my receiving high performance appraisal ratings. If I perform my job well, I am more likely to be promoted..693

4 132 H.K. Knudsen et al. / Journal of Substance Abuse Treatment 24 (2003) Three management practices were measured in this research: job autonomy, support for creativity, and performance-based rewards. The three-item measure of job autonomy was adapted from Pritchard and Karasick (1973). These items asked respondents the degree to which they had sufficient authority to perform their jobs. Support for creativity was measured by five items from Siegel and Kaemmerer (1978). These items asked respondents to what extent they perceived support from the center s management for their development of new ideas and practices. Five items, adapted from Abbey and Dickson (1983), measured performance-based rewards. These items asked respondents the degree to which the organization rewarded employees for strong job performance. A variety of demographic characteristics were included in the analysis. Age, education, gender (1 = female), racial minority status (1 = nonwhite), recovery status (1 = respondent is in recovery), part-time work status (1 = parttime), certification status (1 = certified addiction counselor), caseload (number of clients), salary, and tenure were included as demographic control variables Analysis In order to examine the proposed hypotheses, this research utilized Mplus (version 2.01; Muthen & Muthen, 1998), a structural equation modeling software program. This software allows researchers to evaluate models at both the measurement level and the structural level. Mplus uses confirmatory factor analysis to create latent variables from the shared variance between individual items (Muthen & Muthen, 1998). The main advantage of using latent variables is that the error components of the individual items are parceled out, leaving an unobserved measure that is more valid and reliable than a simple additive scale. In addition, Mplus estimates the structural relations between the latent variables according to the hypothesized model, including the effects of both direct and indirect effects. Mplus produces estimates of all hypothesized paths between variables, t-tests of those path coefficients, and overall measures of model fit. 3. Results 3.1. Demographic characteristics The demographic characteristics of this sample of counselors in private treatment centers provide important descriptive information. A slight majority of the counselors were female (57%), and a vast majority (86%) were white. The sample was 8% black, 3% Hispanic, less than 1% Asian, and 3%, other race/ethnicity. Because the number of respondents in these racial minority categories was so small, they were grouped into a single category for structural equation model analysis. About 60% of the counselors reported that they were in recovery. Generally, the sample tended to be comprised of older counselors. About one third of the counselors were over age 50, while nearly three fourths were over age 40. This preponderance of older counselors was interesting particularly given that the average tenure was quite low. Over half (56%) of the counselors had been with their present employer for less than 4 years. Only 8% had been at the same center for more than 12 years. The counselors that responded to the mail survey were generally quite well educated. Nearly two thirds (63.9%) were certified addictions counselors. About 80% of the counselors who responded had at least a college degree, and about 48% of the counselors had a Master s degree or higher. This high degree of education was not necessarily rewarded by high earnings. In fact, the vast majority (88%) of the counselors earned less than $40,000 per year, even though nearly 80% of the counselors worked full-time. The most common salary was between $25,000 and $40,000, with 57% of the counselors falling within this range Structural model estimates of turnover intention Prior to estimating the structural model between management practices, organizational commitment, and turnover intention, it is necessary to perform a confirmatory factor analysis of the multi-item measures. These results appear in Table 1. The fit statistics reveal a good fit for the model. Given that the sample is large, it is not surprising that the chi-square statistic is significant (c 2 = , df = 427, p <.0001). All of the items have significant loadings on their respective latent variables of interest. Furthermore, the root mean square error of approximation (RMSEA =.051) more than meets the standard of.10 that Kelloway (1998) argues is an indication of good model fit. The structural model results appear in Table 2. The model explains about 66% of the variance in organizational commitment and nearly 60% of the variance in turnover intention. This large proportion of variance explained provides further evidence of the strength of the model. As predicted, the association between job autonomy and organizational commitment is positive (b =.166). There is a significant positive association between support for creativity and commitment (b =.177) as well as between work rewards and commitment (b =.519). Of the three work characteristics, only job autonomy is directly associated with turnover intention (b = -.170). The negative association suggests that greater levels of job autonomy are associated with lower levels of turnover intention. Organizational commitment is positively associated with turnover intention (b =.704). These associations are all in the expected direction and are thus, consistent with the existing literature. It is worth noting that several of the demographic variables were significant predictors of organizational commitment and turnover intention. Older counselors and counselors with longer tenure at their treatment center reported

5 H.K. Knudsen et al. / Journal of Substance Abuse Treatment 24 (2003) Table 2 Structural model results for organizational commitment and turnover intention (standard errors in parentheses) Organizational commitment Turnover intention Variable Estimates Std. Est. Estimates Std. Est. Age.075 (.016).113***.057 (.038).039 Education.030 (.012).059 *.073 (.030).065* Female.019 (.032) (.076).053 Nonwhite.028 (.047) (.113).162* Recovery status.023 (.035) (.085).010 Certification.042 (.034) (.083).119 status Caseload.001 (.001) (.003).004 Part-time.089 (.045).122*.271 (.108).170* Salary.004 (.011) (.026).079** Tenure.007 (.003).046*.001 (.008).003 Job autonomy.094 (.018).166***.210 (.044).170*** Support for.083 (.029).177**.084 (.065).083 creativity Work rewards.370 (.051).519***.006 (.110).004 Organizational (.131).704*** commitment Latent Variable R Note: c 2 = , df = 427, p <.001 Note: RMSEA =.051 * p <.05 (one-tailed test). ** p <.01 (one-tailed test). *** p <.001 (one-tailed test). significantly greater commitment than younger counselors and those with less tenure. Increasing education was negatively associated with commitment. Part-time counselors reported less commitment than full-time counselors. In terms of turnover intention, those counselors with greater human capital resources such as education and being certified in addiction counseling reported greater turnover intention. Counselors of racial minority backgrounds had greater turnover intention than white counselors. Part-time counselors reported less turnover intention than full-time counselors. Finally, salary was negatively associated with intention to quit. 4. Discussion This research provides an empirical test of a model of turnover intention that includes management practices and organizational commitment. The data reveal that job autonomy has direct and indirect effects on turnover intention. The effects of support for creativity and performance-based rewards on turnover intention are mediated by organizational commitment. In addition, salary is negatively associated with turnover intention, suggesting another mechanism to increase counselor retention. These results are supportive of the broader theoretical framework of social exchange. As the norm of reciprocity predicts, employees who perceive that their organizations provide them with more rewarding and supportive environments are more likely to be committed to the organization and hence, less likely to intend to quit their jobs. Some limitations to these findings must be noted. First, the sample utilized was restricted to counselors in privately funded treatment centers; it is unknown if these findings would apply to counselors in publicly funded treatment centers. Additionally, the data are cross-sectional which limits the ability to draw causal inferences. Future research should consider this model using panel longitudinal data. Though the sample consists of slightly more than half of all counselors selected to participate, we are confident that the sample accurately reflects the attitudes and opinions of substance abuse treatment counselors employed in private centers. Because interviews were conducted with the administrator at each of the 400 centers participating in the National Treatment Center Study, we have information about the counselors employed in each center. Thus, it is possible to compare the characteristics of the sampled counselors to the population of counselors employed within these centers. The demographics of those responding to our survey virtually mirror those of the study population meaning that, with respect to these characteristics, the parameter estimates derived from the analyses of these data should not be biased as a result of nonresponse. While turnover of counselors is a major contemporary concern of many treatment center administrators, the results of this analysis show that there may be routes for addressing the problem constructively. Specifically, changes in administrative behaviors may aid in reducing turnover. The findings confirm that the introduction or the enhancement of several basic management practices can either directly influence turnover intention or indirectly affect it by enhancing organizational commitment. Key among these management practices is job autonomy, which has both significant direct and indirect effects on counselors intentions to quit. Increasing autonomy should increase organizational commitment, which should indirectly reduce turnover intentions. Furthermore, the data show that increasing autonomy will directly impact turnover intentions. Granting autonomy to front-line employees such as substance abuse treatment counselors or increasing such autonomy may be more difficult than it appears. Managers may believe that they are giving counselors the right to make decisions about their own work activities, but then undermine their autonomy by enforcing or imposing rules that impede individual decision-making. Managers may also undermine autonomy by repeatedly exercising or threatening to exercise authority, essentially diminishing or eliminating counselors perceived autonomy. In reality, the granting of autonomy can be meaningless without an accompanying change in accountability for decision-making. A partial guideline for granting such autonomy is by including a specific increase in counselors responsibilities for the consequences of the decisions that are made, a strategy typically employed in

6 134 H.K. Knudsen et al. / Journal of Substance Abuse Treatment 24 (2003) participative management (Barker, 1999). It is also critical to make this linkage up front when autonomy is increased so that counselors have the opportunity to accept or reject the change. Support for creativity among substance abuse treatment counselors is a second variable that is significantly linked to organizational commitment which, according to the analysis, should be followed by a decrease in turnover intentions reflecting the increased commitment. This is an important finding given the current emphasis in the substance abuse treatment field about the importance of innovation in treatment and the need to translate findings from research into practice (Institute of Medicine, 1998). As measured, support for creativity is not a direct indicator of the extent of innovation within the treatment center but rather an indicator of the extent to which the organizational environment is receptive to and supportive of efforts to promote new ideas by individuals and groups within the system. To a degree, such a measure has some overlap with the concept of autonomy. Within the context of implementing new ideas, this measure suggests that counselors will increase their commitment when they feel that their ideas for change are respected and supported. If reducing turnover is a concern, and if a treatment program is pursuing the adoption of new treatment techniques, such a finding would not encourage top-down introduction of innovations or their introduction by outside experts, but rather points to the importance of creating ownership for new ideas among substance abuse counselors. Further, this finding suggests that treatment centers should have clear-cut mechanisms within which new ideas can be communicated from the bottom up. Finally, the data suggest the importance of equality across the center in the expected introduction of new ideas, namely that such ideas can come from anywhere, not just from administrators or staff experts. The data also show that the more managers link work performance to work-related rewards, the greater the level of organizational commitment, followed by a decrease in turnover intentions reflecting the increased commitment. While financial compensation represents one possibility, as indicated by the direct effect of salary on turnover intention, it is important to note that this concept encompasses nontangible rewards such praise and recognition. Given the degree of environmental turbulence faced by substance abuse treatment centers, increasing counselors salaries may not be a viable managerial option. However, nontangible rewards may represent a way to enhance organizational commitment, independent of financial incentives. The importance of the measure of rewards used in this research is not necessarily in the level or amount of work rewards, but in the extent to which these rewards are distinctively linked to performance. To an extent, the measurement of the performance/reward linkage may be seen as an element of perceived justice within the workplace (Randall & Mueller, 1995). The implementation or enhancement of this linkage by managers first requires an assessment of the extent to which such a linkage actually exists in a particular workplace. In some settings, particularly public employment, creating such linkages may be more difficult. Once the extent of such linkages is assessed, it is critical that a variety of symbolic means be created to underline such linkages, for while they may appear evident to substance abuse treatment center administrators, they may not be so clear to counselors. Straightforward ceremonies of counselor recognition are an obvious but often underutilized example. In summary, this analysis has utilized a model which accounts for a substantial portion of the variance in substance abuse counselors organizational commitment and intentions to quit. The extent to which intentions to quit are found in any workplace should be a cause for managerial concern and should impel managerial diagnosis of the problem. Through the variables examined in this analysis, three clear recommendations for managerial action to reduce the intention to quit are derived and described. Acknowledgments The authors gratefully acknowledge research support from the National Institute on Drug Abuse (Grant Nos. 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