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Research Brief
A mid adult female nurse checks a senior female patient's temperature with an infrared thermometer. The nurse and patient are wearing protective face masks.

Photo by SDI Productions/Getty Images

A RAND Corporation study of a program intended to reduce turnover of newly hired direct care workers, also known as caregivers, found no significant improvements in caregiver retention or positive return on financial investment. The 12-month program, Transformational Healthcare Readiness through Innovative Vocational Education (THRIVE), took a multipronged approach to addressing employment barriers for entry-level health care workers across three health systems from 2019 to 2021. This research brief summarizes the study's findings and offers recommendations to improve future implementation of THRIVE.

Key Findings

  • Compared with a baseline year, retention rates did not improve across sites during Years 1 or 2 of program implementation.
  • The financial return on investment was negative: For every dollar invested, the program lost $1.09 in Year 1 and $1.11 in Year 2.
  • Caregivers in the lowest pay category or those who identified as Black were more likely than those in the highest pay category or those who identified as White to be terminated from their jobs.
  • The program was implemented differently than originally designed because of staffing shortages, local variations, and restrictions stemming from policies regarding the coronavirus disease 2019 pandemic.
  • Participating caregivers indicated an overall indifference to and neutral perspectives on the program.

In Demand Yet Underappreciated

The direct care workforce employs nearly 4.6 million people (PHI, undated) and is one of the fastest growing occupations in the United States (U.S. Bureau of Labor Statistics, 2022). Caregivers include nursing assistants, home care workers, and residential care aides who provide basic care to older adults and individuals with disabilities in health care settings such as hospitals or residential long-term care (U.S. Bureau of Labor Statistics, 2022).

Despite a growing need for these workers, the supply of the caregiver workforce has not kept up with demand. High levels of workplace stress, low wages, limited training and growth opportunities, and personal stressors plague these caregivers (Stone, 2004), leading to turnover rates as high as 90 percent for caregivers in nursing homes and 35 percent for certified nursing assistants in hospitals. The continuous cycle of onboarding and training new caregivers in these roles poses major challenges for facilities, care recipients, and other caregivers in short-staffed workplaces.

Trying to Address the Underlying Issues

Recognizing the critical need to stem the loss of caregivers, the Ralph C. Wilson, Jr. Foundation funded implementation of THRIVE across ten to 12 facilities in each of three health systems over two years. Year 1 took place from June 2019 to May 2020; Year 2 took place from June 2020 to May 2021. (The coronavirus disease 2019 [COVID-19] pandemic required some in-person aspects of implementation to be conducted virtually.)

THRIVE sought to surmount the barriers that contribute to high turnover by giving caregivers the tools they need to navigate problems in their professional and personal lives and increasing their satisfaction with the training they receive. The curriculum consisted of a four-day core session and a series of follow-up trainings. All newly hired caregivers at the implementation sites were required to participate in the program, though certain supports (such as the frequency of one-on-one coaching check-ins) were customized to each participant according to the results of a comprehensive risk assessment for each caregiver. THRIVE also supported site-specific program management, infrastructure and partnership development, and financial assistance.

Line drawing of one hand reaching out to another

Image by MuhammadZulfan/Adobe Stock

Evaluating the Effects of THRIVE

Initially, the plan was to evaluate THRIVE over three years of implementation compared with a baseline year (June 2018 to May 2019). However, when RAND did not find positive changes after the second year of implementation, the foundation chose to pause THRIVE implementation.

Retention and Associated Return on Investment

RAND researchers used data from participant surveys and interviews, data on length of tenure and reasons for termination, and observations of the THRIVE training sessions to evaluate the effects of THRIVE on retention and financial sustainability. They found no statistically significant changes in retention of the nearly 3,000 caregivers who participated in the first or second year of the program compared with the baseline year. Because the COVID-19 pandemic could have obscured some program effects, RAND also examined the first nine months of the first year of implementation (i.e., prior to March 2020) against the first nine months of the baseline year and still found no improvements or significant differences in retention.

THRIVE cost an average of $1,772 in Year 1 and $2,263 in Year 2 per caregiver, with about half of that going to labor costs for implementation staff. The program did not break even or generate a positive financial return on investment (ROI): The ROI was negative at –$1.09 in Year 1 and –$1.11 in Year 2. That is, for every dollar invested in the program, more than one dollar was lost, largely because of the lack of improvement in retention. Given the costs of the program, RAND found that retention rates would have needed to exceed 100 percent for the program to break even.

Predictors of Retention

Researchers examined associations between retention and a number of participant characteristics, including pay rates (i.e., wages), full- versus part-time status, race, and gender. Two factors—pay rate and race—emerged from the data as significant predictors of retention in both program years. Caregivers in the lowest pay category or those who identified as Black were more likely than those in the highest pay category or those who identified as White to be involuntarily terminated from their employment. At the organizational level, higher levels of burnout also predicted caregiver intent to leave within the next six to 12 months.

In contrast, at the program level, the follow-up training sessions were consistently associated with improvements in such outcomes as absenteeism, relationships with managers and other colleagues, and commitment to the organization and to the field of caregiving. This latter finding, however, may reflect a bias in the types of participants who attended these sessions and their engagement with the organization.

Program Strengths and Opportunities for Improvement

[THRIVE is] fine. . . . It also kind of feels unnecessary. It's all good intentions but at the end of the day, I don't think it matters.

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THRIVE participant

Many caregivers appreciated the resources provided through the program to orient employees to the health system and to help them meet other caregivers and learn about self-care techniques. One participant said, "It really taught me that you need to be open when communicating." Both caregivers and program staff emphasized the passion and enthusiasm of THRIVE staff in delivering the program. In interviews, many caregivers indicated that they did not feel that the program benefited them personally but would still recommend THRIVE to a friend or a colleague with less experience in caregiving or in working for a health care institution.

Most feedback from caregivers on the program was neutral or indifferent. One caregiver said of the program, "It's fine. The person [coach] I have is really kind. I don't know, it also kind of feels unnecessary. It's all good intentions, but at the end of the day, I don't think it matters."

Caregivers often had difficulty recalling certain components of THRIVE or confused certain program curriculum components with the health system's general orientation. Additional clarity about the program and its goals may help set expectations for caregivers. Program activities and facilitation could be refined to better target adult learners with cultural competency. Expanding and improving the demographic and background diversity of THRIVE staff would also strengthen the program.

Limitations of the Study

Although RAND attempted to mitigate several challenges throughout the evaluation through data management or analysis adjustments, the findings from the evaluation should be interpreted with caution. Data collection was not optimal: Most data were from the second year of implementation because of approval delays; there were issues with data quality and consistency; and there were documentation issues across sites. In addition, RAND was able to gather input and feedback only from caregivers currently enrolled in the program. The COVID-19 pandemic compounded implementation challenges and introduced a largely unmeasurable external factor that might have affected the program results.

Line drawing of a person's hand being held in someone else's hands

Image by MuhammadZulfan/Adobe Stock

Considerations for Future Retention Programs

Although this implementation of THRIVE did not achieve its goal of increasing retention among program participants, the RAND evaluation did reveal important lessons learned. Future implementors of similar programs should consider

  • whether a mandatory or "one-size-fits-all" approach to the program is appropriate
  • whether alternative interventions, such as pay rate increases, may have a greater impact on the specified goal (i.e., retention)
  • how to involve caregivers in the design and implementation of the intervention
  • factoring the levels of the health system's readiness and cultural supportiveness into determination of appropriate interventions, including systemic issues that may influence retention
  • increasing the diversity of backgrounds, experiences, and demographic characteristics of those developing and delivering the intervention
  • developing clear documentation for program processes and data tracking
  • articulating program goals to leadership, managers, and caregivers in a clear manner from an early stage of the buy-in process.

Health systems and facilities that invest in these actions will be more likely to implement a successful program that helps support caregivers in their roles while also addressing the urgent need for a more stable direct care workforce.


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