Factors Impacting Retention of Aged Care Workers: A Systematic Review

Retention of care support workers in residential aged care facilities and home-based, domiciliary aged care is a global challenge, with rapid turnover, low job satisfaction, and poorly defined career pathways. A mixed-methods systematic review of the workforce literature was conducted to understand the factors that attract and retain care staff across the aged care workforce. The search yielded 49 studies. Three studies tested education and training interventions with the aim of boosting workforce retention and the remaining 46 studies explored opinions and experiences of care workers in 20 quantitative, four mixed-methods and 22 qualitative studies. A range of factors impacted retention of aged care staff. Two broad themes emerged from the analysis: individual and organisational factors facilitating retention. Individual factors related to personal satisfaction with the role, positive relationships with other staff, families, and residents, and a cooperative workplace culture. Organisational factors included opportunities for on-the-job training and career development, appropriate wages, policies to prevent workplace injuries, and job stability. Understaffing was often cited as a factor associated with turnover, together with heavy workloads, stress, and low job satisfaction. With global concerns about the safety and quality of aged care services, this study presents the data associated with best practice for retaining aged care workers.


Introduction
Globally, one of the most rapidly growing sectors of the care economy is aged care [1].People in developed countries can expect to live at least a decade longer than the global average of 73 years [2].Of concern, the proportion of the population requiring health and care services is increasing due to an ageing demographic [3].At the same time, the share of the population that is able to deliver services is decreasing [4].The size of the frontline aged care workforce, such as personal care attendants, nursing assistants, and allied health assistants, will need to quadruple to meet the demand of ageing societies [5].The aged care workforce is reliant on a supply of workers that predominantly consists of women with few qualifications, in labour-intensive roles [6,7].These staff provide essential management of mobility, cognitive impairment, toileting, bathing, and feeding [8].It is estimated that more than half of aged care residents live in facilities with insufficient staffing for person-centred care [9].
Upwards of 25% of aged care workers in countries such as the United Kingdom and Australia spend less than one year in care support roles [10][11][12].The median annual turnover for nursing assistants in the United States is nearly 99% [13].Staff turnover in aged care settings is negatively associated with the quality of care [13,14].Turnover is also associated with falls [15], infection rates [16], and low resident and staff satisfaction [17,18].Supervisors of the care workforce are usually registered and enrolled nurses who also have critical staff shortages [19].To improve care experiences and outcomes for older people, care workers need to be trained, safe, and adequately supported to be retained in the workforce.
Evidence-informed, tailored strategies for workforce redesign are arguably needed to recruit and retain aged care workers [20] and to prevent burnout [21] and safety incidents [22].A variety of rewards are recognised and valued by staff [23].Incentives include adequate pay rates [24], safe and positive working conditions [25,26], and suitable geographical locations for employment [27].The extent to which other determinants of workforce retention, such as comprehensive orientation and ongoing training at the workplace, apply to aged care workers is currently not known [28].
There is a need to better align the motivations and needs of aged care workers to the requirements of aged care support roles, to improve the length of service tenure [23].The main aim of this systematic review is to identify, summarise, and aggregate the quantitative and qualitative evidence related to the retention of care workers in aged care homes, respite care, retirement villages, and home settings.A second aim is to identify barriers and facilitators to care staff retention in the aged care sector.

Materials and Methods
A mixed-methods design following the JBI convergent integrated approach [29] was used to synthesise quantitative and qualitative evidence.This approach reflected the complexity of research questions in health and social care and afforded deep understanding of the issues [30].The results were reported in accordance with the preferred reporting for systematic reviews and meta-analyses (PRISMA) guidelines [31] (Table S1) and the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) checklist [32] (Table S2).The review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD:42023440055).

Search Strategy
A systematic literature search identified articles from Medline, Embase, PsycINFO, CINAHL, and AgeLine.Articles were limited to peer-reviewed, primary studies published in the English language from January 2012 to July 2023 to provide a contemporary overview of the evidence.No geographical limitations were placed on the search.The search was developed and conducted with a university academic librarian, with keywords informed by MeSH headings and focused on the concepts of population (i.e., nursing assistant and other relevant terms), setting (i.e., residential aged care), and outcomes of interest.These outcomes included, but were not restricted to (1) workplace satisfaction: job status, turnover or intention to leave, stress (burnout, occupation, job), attitudes, perceptions, workplace violence or danger, absenteeism, job fulfilment, conflict resolution; (2) barriers and facilitators: motivation, supports, challenges; (3) workload: rostering, supervision, understaffing, recruitment, retention, empathy or compassion fatigue; (4) professional development: education, ongoing training, job or career flexibility, professional identity, judgement, career opportunities and pathways; (5) clinical environment: working conditions, leadership, manager support, mentorship, occupational health and safety; and (6) interventions to optimise recruitment and retention.Additional articles were searched for via reference lists of included studies, relevant systematic reviews, trial registries (i.e., WHO International Clinical Trials Registry Platform, ClinicalTrials.gov,and Australian New Zealand Clinical Trials Registry), and grey literature (i.e., Google Scholar, social and aged welfare organisational websites).The search strategy for Medline is detailed in Table S3.Identified articles were imported into Covidence [33] and duplicates removed.

Eligibility and Screening
An aged care worker was defined as a person employed to independently deliver direct care under the overall supervision of a registered or enrolled nurse [34] or under the supervision of an allied health professional or medical practitioner, within an aged care setting (residential aged care or home-based aged care).A widely accepted definition of older person is over 60-65 years [35]; however, we did not apply age limits to inclusion criteria.Residential aged care facilities (also known as care homes, long-term care facilities or nursing homes) were defined as facilities providing 24 h nursing and care to older adults [36].Home-based care (domiciliary care) was defined as the provision of scheduled, as-needed, healthcare within an older person's home.In the case of a study including both aged care workers and other employees within aged care, the study was only included if the data related to aged care workers could be separated or the number of aged care support workers represented a clear majority (>70%) of participants.Analysis of the professional care workforce such as doctors, nurses, and physiotherapists was not performed as this has been covered in a separate manuscript [37].Datasets were limited to the past 10 years to focus on contemporary evidence concerning the aged care sector, noting changes including the removal of distinction between high-and low-level care, establishment of "home care" and means testing for contributions to care [38].The inclusion and exclusion criteria are listed in Table 1.The title, abstract and full-text articles were screened independently by two authors (C.T., J.M.) who applied the criteria from Table 1 to determine eligibility.Disagreements were discussed and resolved, involving a third reviewer (M.M.) when necessary.

Methodological Quality
The mixed-methods appraisal tool (MMAT) [39] was used by two authors independently (C.T., J.M.) to assess methodological quality of the selected studies.Consensus was achieved through discussion among the two reviewers, with incorporation of a third author (M.M.) as required.The design of the MMAT allows for analysis of studies across a range of methods, with different criteria to describe and evaluate mixed methods, qualitative and quantitative studies.These criteria assess factors that impact risk of bias, completeness, and transparency of studies.Following updated recommendations [40], MMAT scores were not allocated a numerical value; instead, studies were ranked low, moderate, or high quality.Due to the limited literature, all studies were included in data synthesis; however, study quality was considered in interpreting the synthesised evidence.

Data Extraction and Analysis
A data extraction sheet was purposefully developed, based on the JBI mixed methods data extraction form [30], and used to collect data related to the study aims, setting, design and methodological framework, sampling methods, data collection methods, demographics of the care worker populations, and key findings related to review outcomes.For interventional studies, an abbreviated template for intervention description and replication TIDieR checklist [41] was used to capture details of the intervention, who provided it, and how it was delivered.A single author (C.T.) completed this process with data checked for accuracy, completeness, and quality by another author (M.M.).Where studies included aged care support workers and other employees in aged care, only the data relating to care workers were extracted where possible.
Quantitative data were tabulated, with descriptive statistics, p-values, and effect sizes for mean score differences presented where available.The results were then narratively synthesised.Originally, the research team had planned to calculate change scores where relevant data, such as workforce attrition or retention rates, were sufficiently reported; however, limited data availability prevented this.Qualitative data pertaining to the research question were extracted and managed using NVivo software (release 1.7) [42].An interpretive description approach was followed to allow for representation of subjective experiences at both individual and wider population levels [43].The data were analysed thematically, with initial reading and rereading for deep understanding [44].Key words, phrases, and sentences relevant to the research question were synthesised and codes developed.These were refined and grouped into themes and subthemes, then reviewed and discussed (C.T., M.M.) until consensus reached.
Following the JBI mixed methods review methodology [30], the results of quantitative and qualitative components were aggregated.The narratively synthesised quantitative results were categorised and summarised to create subcategories to fit together with the qualitative synthesis.This generated a new set of organised findings regarding factors influencing aged care worker retention.A subgroup analysis pertaining to the care setting was not performed because there were minimal home-based care studies meeting the inclusion criteria.

Identified Studies
As seen in the PRISMA flow diagram (Figure 1) [31], a total of 2506 studies were identified through database searches, with an additional 29 studies found through citation searching, websites, or organisation releases.Following removal of duplicates, 2460 studies were independently screened for eligibility, with 143 assessed as potentially eligible.Some studies (n = 26) were excluded because data related to aged care workers could not be separated from professionals or administrators working in aged care.Some were excluded because data were derived from assessments that occurred prior to 2012 (n = 21), or outcomes were not related to factors influencing retention of aged care workers (n = 16).In total, 49 peer-reviewed, English language studies reporting primary research results were included (23 quantitative studies, 4 mixed-methods investigations, and 22 qualitative analyses).Grey literature was reviewed by two assessors.This led to identifying gaps in research needing to be addressed, including exploration of the specific needs of migrant care workers, the workforce challenges in respite aged care, and strategies to improve recruitment of the aged care workforce, particularly in regional and remote communities.
gaps in research needing to be addressed, including exploration of the specific needs of migrant care workers, the workforce challenges in respite aged care, and strategies to improve recruitment of the aged care workforce, particularly in regional and remote communities.[31] outlining study selection process.

Study Characteristics
The characteristics of studies are presented in Tables 2-4.Three studies implemented strategies to improve retention.Of the studies applying an intervention, two were randomised controlled trials [45,46] and one used participatory action research with pre-post assessments [47].The use of descriptive surveys and questionnaires with a cross-sectional (n = 20) or longitudinal (n = 2) design were reported in all quantitative descriptive and mixed-methods studies.The exception was the trial by Sharma et al. (2022) [48] who used human resource records to assess the relationship between wages and aged care staff turnover.Qualitative study designs included interpretative (n = 18), long ethnographic (n = 2), grounded theory (n = 1), and phenomenological approaches (n = 1).For these studies, individual interviews were most common (n = 14), or focus groups (n = 5), or a combination of data collection methods (n = 3).Supplementary Tables S4-S6 show that purposive sampling was most favoured (n = 33).Supplementary Tables S4 and S5 highlight a wide range of outcomes relevant to care worker retention.These were captured using surveys on workplace culture, work-related injuries, job satisfaction, leadership styles, mental health of staff, intention to leave, wages, work-related stress, and the impact of the COVID-19 pandemic on care workers.[31] outlining study selection process.

Study Characteristics
The characteristics of studies are presented in Tables 2-4.Three studies implemented strategies to improve retention.Of the studies applying an intervention, two were randomised controlled trials [45,46] and one used participatory action research with pre-post assessments [47].The use of descriptive surveys and questionnaires with a cross-sectional (n = 20) or longitudinal (n = 2) design were reported in all quantitative descriptive and mixed-methods studies.The exception was the trial by Sharma et al. (2022) [48] who used human resource records to assess the relationship between wages and aged care staff turnover.Qualitative study designs included interpretative (n = 18), long ethnographic (n = 2), grounded theory (n = 1), and phenomenological approaches (n = 1).For these studies, individual interviews were most common (n = 14), or focus groups (n = 5), or a combination of data collection methods (n = 3).Supplementary Tables S4-S6 show that purposive sampling was most favoured (n = 33).Supplementary Tables S4 and S5 highlight a wide range of outcomes relevant to care worker retention.These were captured using surveys on workplace culture, work-related injuries, job satisfaction, leadership styles, mental health of staff, intention to leave, wages, work-related stress, and the impact of the COVID-19 pandemic on care workers.Major themes included overcoming prejudice from residents and locally born peers; the importance of peers with a similar cultural background; the benefits of working within an in-demand sector; the cost-effectiveness of working and living in a regional community; and the challenges of communication being an essential part of the role but coming from an English as a second language background.
High ACA: aged care assistant; AHA: allied health assistant; CA: care aide; CaLD: culturally and linguistically diverse; CG: control group; CNA: certified nursing assistant; DCW: direct care workers; DON: director of nursing; LN: licensed nurse; HCW: home care worker; HHA: home health aide; IG: intervention group; LTCF: long-term care facility; MMAT: mixed methods appraisal tool; NA: nurse assistant; NH: nursing home; NHA: nursing home administrator; PCW: personal care worker; PSW: personal support worker; RACF: residential aged care facility; RCT: randomised controlled trial; RN: registered nurse; SNF: skilled nursing facility.
Studies were conducted across the globe, with most in the United States (n = 18), followed by Australia (n = 10), Canada (n = 5), Sweden (n = 5), and Taiwan (n = 4).Others were from Hong Kong, China, Korea, Austria, France, Denmark, the Netherlands, and Slovenia, providing global insight into factors influencing aged care worker retention.Sample sizes varied.For example, they ranged from the Charlesworth et al. (2020) [53] subgroup analysis of a nationwide aged care workforce survey, investigating the effect of migrant status on casual and underemployment amongst 7114 personal care attendants from residential and home aged care services, to seven migrant aged care workers providing insight on their experiences working in regional areas in the study by Winarnita et al. (2022) [93].Supplementary Tables S4-S6 show that 77-100% participants were female.Factors related to migrant aged care workers were explored in nine studies [53,56,59,64,66,72,81,88,93].Overall, the studies included people employed as personal care attendants, certified and noncertified nurse assistants, direct care workers, patient support workers, home health assistants, and allied health assistants in addition to professional and administrative staff.Most studies (n = 47) were conducted in residential aged care facilities.Only four studies included staff working in home-based care [53,80,81,86].

Convergent Qualitative Synthesis
Data synthesis was aligned to two main themes of individual and organisational factors pertaining to staff retention.Individual or personal factors were defined as variables important to the care workers because of personal beliefs and life experience, in or out of the workplace.Organisational factors were defined as variables that could be changed or influenced by the organisation with impact on the care workers.These were derived from thematic analysis of the included studies, with the ecological framework of McLeroy (1988) [94] used as a stimulus during the initial formation of themes to conceptualise and understand aged care worker retention.According to the McLeroy framework, levels of influence are factors that examine relationships of individuals within their workplaces, communities, and broader society.Detailed synthesised findings are found in Supplementary Table S7.
Three intervention studies sought to improve individual factors for aged care workers (Supplementary Table S4).The randomised trial by O'Brien et al. (2019) [47] reported that group-based cognitive behavioural training promoting flexibility in response to workplace stress in care home staff significantly reduced staff absences and mental health symptoms.The participatory action research by Ericson-Lindman et al. (2017) [46] involved collaborative, group-based training with registered nurses and nursing assistants together, whereby scenarios involving troubled conscience in the workplace were explored.By learning how to constructively deal with feelings of being unable to deliver a quality of care expected of themselves, participants noted an improvement in work-related performance and social support between workers.The trial by Jeon et al. (2015) [45] applied a randomised design to assess the effect of providing care home middle managers with a 12-month supported leadership program and found that both supervisor support and management behaviour towards care workers significantly improved; however, turnover and intention to leave did not differ between groups.

Organisational Factors
At a macro-organisational level, local rules, regulations, opportunities, and constraints affected staff retention.There were some reports of a lack of continuous, competent staff [74,91] and perceived understaffing [77][78][79]81,84,[89][90][91][92].This was thought to limit opportunities for person-centred care [76,85,86,92] and increased turnover [85].Whilst casual employment offered flexibility [56,72,93] and higher payrates per hour, care workers expressed a desire for schedule control [77,89].Teams where care workers were empowered to manage rostering found absences less impactful [50].Having job stability was found to be important in reducing workplace stress [91] and increased retention [69].However, many care workers reported lower job stability when providing home care, compared to those employed by a residential care facility, due to clients' ability to enact personal preferences for care workers [86].
Local rules and role structures adversely affected care workers, with burnout [71] and low job satisfaction associated with long shift lengths, split shifts, or insufficient break allowances [71, 73,86].Heavy workloads [69], uncertainty of scope of practice [86], and limited capacity for older workers to perform nonphysical tasks [91] negatively impacted intention to stay [86].Additionally, work-related injuries were reported at higher rates in older, female care workers [54], in migrant workers, and where assistive devices were not used for manual handling of residents [66,70], with an increased level of intention to leave [54].
The education and training of aged care staff were key determinants of retention.There were reports of insufficient onsite training before starting work [75,77,81,85], with some care workers feeling underprepared for both the physical demands of the role, and the emotional aspects of caring for older adults, especially at end of life [78][79][80].Some migrant workers with overseas nursing qualifications reported the benefits of taking indemand, lower-skilled roles in aged care whilst waiting to finalise nursing registration in their new country [56,72,88,93].Others reported stress associated with a lack of career pathways, training, or formal education [51,73,82,86,88].When career opportunities were available, they were often difficult to access financially or geographically, or not relevant to the scope of work [86].Low local unemployment levels also impacted retention, with jobs in other industries, such as retail, offering similar salaries to aged care work, but with lower perceived work demands [58,77].Facilitators to retention included promotion opportunities [69], schedule or roster management by the care workers, and safety training [90].When a workforce was unionised with greater collective power [49] or a facility had lower proportions of residents with psychiatric illnesses [58], retention of care workers was higher.
The policy setting influenced worker behaviours.Policies regarding minimum ratios of professional to care worker staff or staff to resident ratios differed globally [60,62,[68][69][70].Supportive supervision levels were reported to be greater in the presence of higher professional-to-care worker ratios [60,70].Whilst some studies reported the positive aspects of the requirement to have dedicated qualified nurses supervising care workers [60,68,87], there were significant challenges faced by nurses in managing a casualised, high-turnover workforce with need for continual training of new staff [89].Despite efforts by governments worldwide to reform the working conditions of this sector, some care workers in our review expressed frustration with working in an unregulated wage system [86].They felt that retention would improve if wage rises were associated with excellent performance [85] or length of tenure [89].Increased rates of workplace injuries [70] and intention to leave [69] were reported when care worker staff-to-resident ratios were low.This was exacerbated by the COVID-19 pandemic, where restrictions on other health professionals placed an additional burden on care workers to perform duties beyond their scope of practice [83].

Discussion
Care staff are highly sought after worldwide yet retaining them in aged care roles is challenging.This review shows that the intention of personal care assistants, nurse assistants, and allied health assistants to stay working in the aged care sector was related to individual and organisational factors.Policies on wages, staff ratios and safety standards also impacted recruitment and retention.Our review identified studies from countries across European, Oceanian, Asian, and North American regions where life expectancy is typically longer [35].We acknowledge that the nature of work for older adults' care personnel in these regions will differ, as people spend more time in need of care, so knowledge of advance care planning and palliative care is required [95][96][97].It is further noted that aside from population size and life expectancy, there are differences between countries regarding social security systems, impact of religion, and local economic situations [98,99].These are some of the "key elements" of the older adult care workforce that affect turnover intention.
Our review highlighted that several individual factors were related to workforce retention.More positive lived experiences working in aged care were related to better retention, as was high job satisfaction.Retention was better when care workers felt supported by peers and supervisors and when there was capacity in their workloads to provide person-centred care.In agreement with a recent review on caring self-efficacy in direct care workers [100], we found that being able to establish compassionate relationships and meet the needs of residents was a key driver to remaining in the workforce [73,82,84].Reducing sources of care worker stress also helped [73,75,[84][85][86]89].Evaluation of effectiveness of retention strategies was limited due to only three studies implementing an intervention.
Organisational factors also played a role.Retention was stronger when managers had positive leadership styles.Local procedures regarding staff rosters, shift lengths, split shifts [71, 73,86], and enabling staff to contribute to roster management were facilitators [58,64,91].The study by Brown et al. (2016) [50] described a staff responsibility approach where aged care workers were responsible for rostering.There was an enhanced ability to manage workloads, and this was associated with lower turnover rates compared to other care homes.As with recent government reports [36,101], we found that workplace health and safety was a predictor of retention, with workplace culture impacting whether occupational recommendations were adhered to [66,70,73,76].For employers, organisational factors such as creating a positive workplace culture, ensuring good communication between leadership and staff, and ensuring a safe workplace through appropriate equipment-and facility-specific training aided care worker retention.
Across the world, there is a shift in aged care service provision to be more personcentred and value-based [18,102,103].The quality of care remains dependent on recruiting and retaining very large numbers of the care workers providing the bulk of direct care to residents [104][105][106].In recent years, care quality has come under increased scrutiny, and practice and policy concerns have been raised about staffing levels, recruitment, and retention [107].Some have proposed that a need exists for better regulation of this workforce, with safety and quality of care at risk [36].The recent Australian Royal Commission into Aged Care Quality and Safety (2021) [36] claimed that over 30% of people accessing residential or home-based aged care services experience substandard levels of routine personal or comprehensive care.Within our review, some care workers also shared the sentiment that care quality is not meeting basic expectations [84,85,89].Some care staff expressed frustration with services not covering staff absences [77][78][79]84,[89][90][91], insufficient pre-employment training [75,[77][78][79]85], or poor cooperation across teams [69,75,77,90].Some care workers felt underprepared for the emotional engagement required to deliver care in an empathetic and meaningful way.In some countries, the aged care workforce is multicultural and includes first-or second-generation migrants in low-paid roles [108].Similar to other research in this area [109,110], migration of people suited for aged care work was hindered by visa pathways that channelled them into "low-skilled" nonprofessional care roles [72,81,93].Migrant aged care workers are more likely to be on casual contracts [53,56].Often, they seek more work hours, hold multiple jobs, and work at a lower skill level than afforded by their overseas qualifications [10,53,111].A recurring theme was that the cultural diversity and cultural competence in the aged care sector needs to be optimised to accommodate care worker needs and to give staff opportunities for education and training [112].
There were several limitations of our review.Due to the low yield and heterogeneity of quantitative data, we were unable to complete a meta-analysis.Also, the review yielded few articles on retention of staff in home-based care, despite the preference of many older people to live in their own home as they age [113,114] and the known issues of staff shortages in this sector [110].It was anticipated that findings would include examination of the impact of vaccine requirements during the COVID-19 pandemic, yet this did not emerge in the results.Also, we were not able to perform a detailed policy analysis due to variations across countries and exclusion of grey literature; this is recommended for future investigations.

Conclusions
Retention of aged care workers is a growing challenge worldwide.This systematic review summarised and aggregated contemporary evidence regarding retention of aged care workers, with analysis of retention strategy effectiveness limited by a low yield of interventional studies.This review highlighted the need for better support of care workers to keep them in employment.As well as optimising pay, workloads, and conditions, there is a need for reform of education and training, better career pathways, and more optimal support of worker wellbeing.

Table 1 .
Inclusion and exclusion criteria.

Table 2 .
Overview of quantitative studies.
Associations between high (vs low) retention rates of NAs and greater leadership/staff empowerment scores; low NH administrator turnover; high NH occupancy rates; presence of a union; greater hours per day allocated to residents.
Musculoskeletal injuries found to be experienced at high rates by NAs working in NHs; in mainly older, female workers who perceive work to be more stressful; associated with an increased intention to leave and a perceived health status of "not good".

Table 3 .
Overview of mixed methods studies.

Table 4 .
Overview of qualitative studies.