Business Management Research & Applications: A Cross-Disciplinary Journal 1 Improving Retention Among Patient Care Assistants in Hospitals Post COVID-19 Pandemic: A Qualitative Inquiry Study Dr. Latrina Hyde| Columbia Southern University, Orange Beach, Alabama Robert Goldwasser | Columbia Southern University, Orange Beach, Alabama Contact: lhyde1@fuse.net Abstract Patient Care Assistant (PCA) retention in Midwest hospitals has become the topic of discussion after the COVID-19 pandemic. PCAs experienced longer working hours, less time with loved ones, and increasingly stressful environments during the COVID-19 pandemic. The mental health impacts of living and working in a pandemic have been well documented. PCAs felt the brunt of this impact throughout the pandemic as new surges emerged, deaths mounted, capacity depleted, and risks on the job remained. In this study, the researcher used a qualitative inquiry study to investigate why HR leaders and unit managers lack the strategies to retain PCA staff during and after the COVID-19 pandemic. The researcher conducted face-to-face interviews with HR leaders and unit managers on the front lines during and after the COVID-19 pandemic in a hospital in Midwest Ohio. The researcher used purposive sampling to ensure a diverse and representative sample of appropriate participants for this qualitative inquiry study. The researcher's study included multiple uses of data sources and direct encounters to enhance the study's validity. The researcher recognized three principal themes that HR leaders and unit managers could use to retain PCAs during and after another pandemic. The researcher identified three key themes: compensation, burnout, and PCA-to-patient ratios. This research has implications for PCAs who desire equitable compensation and incentives during another pandemic and for the organization to implement successful strategies to ensure PCAs are supported during and after another pandemic. Keywords: PCA retention, burnout, pandemic, HR strategies, compensation June 2024 | Volume 3, Number 2 2 Introduction Retention of Patient Care Assistants (PCA) is a significant concern for healthcare providers (Chatzoudes & Chatzoglou, 2022). Experts and providers report a current shortage of PCAs, partly because of patients' increasingly complex care needs (Chatzoudes & Chatzoglou, 2022). Moreover, several factors combine to constrain the current and future supply of PCAs. Numerous studies reported decreased job satisfaction levels among PCAs, potentially leading to them pursuing other occupations (Chatzoudes & Chatzoglou, 2022). Demographic changes over the coming decades may also worsen the shortage of PCAs in hospitals (Chatzoudes & Chatzoglou, 2022). As the baby boomers' population increases, the demand for PCAs is expected to grow dramatically, while the supply of PCAs who have traditionally filled these jobs will remain virtually unchanged (Chatzoudes & Chatzoglou, 2022). Several factors contribute to hospitals' difficulty retaining PCAs, including relatively low wages and few benefits (Chatzoudes & Chatzoglou, 2022). In addition, the research found that the physical demands of the work and other aspects of the workplace environment led to difficulties in retaining PCAs (Chatzoudes & Chatzoglou, 2022). Hospitals striving to retain their PCAs face the challenge of meeting the needs of PCAs while competing with other area hospitals offering higher pay and sign-on bonuses (Chatzoudes & Chatzoglou, 2022). PCAs receive some of the lowest wages in the United States. The PHI reports the median hourly wage in 2022 for all PCA workers in Ohio was $13.83 an hour (PHI, 2020). Health insurance coverage for PCA workers is just as dismal. One in every four PCA workers lacks healthcare coverage, and only 53% have coverage from their employer (PHI, 2020). Moreover, a study based on data from the 2022 National Nursing Home Survey, the National Nursing Assistant Survey, and the Area Resource File surveyed— whether wages, benefits, or training—found that organizational culture affected increasing the job tenure of PCAs in hospitals. Overall, research shows the extrinsic rewards of paid time off and a pension are the most important determinants of job tenure (Wei et al., 2022). PCA workers enrolled in employer health insurance plans have more than twice the tenure of those without employee coverage (Wei et al., 2022). This study investigated if higher wages and job satisfaction significantly impact the retention of PCAs. Data from the 2022 National Nursing Assistant Survey shows that satisfaction with wages had the second strongest association with intrinsic and overall job satisfaction (Wei et al., 2022). It was also found that the higher the intrinsic job satisfaction reported by PCAs, the lower their intent to leave. Thus, satisfaction with wages affects the intent to leave through its direct effect on intrinsic job satisfaction (Wei et al., 2022). Seavey (2018) surveyed PCAs in a consumer-directed program to investigate the impact of wages and benefits on retention (Seavey, 2018). Seavey (2018) found that access to health insurance through their job was one of the significant reasons PCAs accepted job offers and stayed longer (Seavey, 2018). In addition, Seavey (2018) showed that when the wages of PCA workers in San Francisco County doubled, the retention rates of new PCAs increased from 39% to 74% (Seavey, 2018). In a survey of 255 PCAs in 15 hospitals, Seavey found satisfaction with benefits was consistently important to PCAs' commitment to their jobs (Seavey, 2018). While training and organizational culture have a documented influence on PCA retention, they are not the only factors impacting it. Some studies have not found a strong link between wages, health insurance, and retention (Seavey, 2018). The researcher provided hospital strategies that can be used to retain PCAs. Background of the Study Retention is a phenomenon that allows organizations to retain top talent and is one of the critical issues facing organizations today (Chatzoudes & Chatzoglou, 2022). PCA retention is important to healthcare organizations in maintaining patient care and patient safety. Patient care assistant retention affects organizational performance, employee morale, and productivity. Patient care assistants typically provide most of the hands-on care in hospitals, including assistance with bathing, dressing, and eating (Donnely, 2022). The pandemic triggered a mass exodus Business Management Research & Applications: A Cross-Disciplinary Journal 3 from the profession soon after the pandemic (Falatah, 2021). PCAs comprised 64% of the healthcare industry's employee full-time equivalents (FTEs) (Sun et al., 2023). After the transition into new stages of the pandemic, hospitals and analysts have noticed a trend in PCA talent. After the distressing experiences of the pandemic in people's work and personal lives, many PCAs are considering resigning to find work elsewhere. Now, more than ever, PCAs seek meaningful work that aligns with their values and offers them flexible work and benefits (Falatah, 2021). In many cases, healthcare organizations that were slow to adapt to flexible work and did not emphasize the employee experience have already started noting the consequences (Sun et al., 2023). Hospitals have made many strategic efforts to increase PCA retention. However, despite efforts by hospitals to retain their PCAs, retention is a significant problem (Wei et al., 2022). Examples are sign-on bonuses, tangible benefits, increases in paid time off, incentive pay, and adapting to new scheduling practices (Donnely, 2022). According to a 2022 American Health Care Association (AHCA) survey, the retention rate for hospital patient care assistants was 35.6% (AHCA, 2020). For patient care assistants, one study estimated the retention rate of PCAs who had been on the job for less than a year was 20% to 50%, with 80% to 90% leaving within the first year (PHI, IFAS, 2022). The reasons for this low retention are varied. Although the jobs themselves are rewarding for many PCAs, workers often face such challenges as low pay, a lack of health insurance, poor or inadequate training, little or no advancement opportunities, poor relationships with their supervisors, physical and emotional demands, and a lack of respect by management, residents' families, and society overall (Duffield et al., 2009). According to Castle and Engberg (2019), high turnover rates of patient care assistants are associated with the worst quality of care for hospital patients (Castle & Engberg, 2019). Castle and Engberg's (2019) qualitative study examined the association between retention and turnover in hospitals using 14 care quality indicators. The indicators included rates of patient acuity and physical restraint use, catheter use, mobility, loss of bladder or bowel control, and increased depression or anxiety (Castle & Engberg, 2019). The analysis showed a decrease in retention from medium (40-80% per year) to high levels (more than 80% per year), associated with lower quality factor scores. However, even higher retention levels were not associated with a further decrease in quality (Castle & Engberg, 2019). In an earlier study, Castle and Engberg found that higher quality of care was associated with high patient-care assistant retention in 854 hospitals in six states (Castle & Engberg, 2019). Bostick et al. (2016) systematically reviewed 87 research articles and government documents published from 2019 to 2021 to determine the link between staffing and quality measures in hospitals (Bostick et al., 2016). Bostick et al. (2016) found a significant relationship between low retention and poor-quality outcomes for residents (Bostick et al., 2016). Lower retention rates in hospitals have been associated with greater use of physical restraints, catheters, and psychoactive drugs, as well as more contractures and quality-of-care deficiencies (Jones et al., 2018). Low retention rates also affect hospitals' financial health. An estimate of the minimum direct cost of replacing a patient care assistant is $2,500 (Seavey, 2018). However, this does not consider the indirect costs of retention, which include the following: (a) lost productivity until a replacement is trained; (b) lost client revenues and/or reimbursement; (c) increases in worker injuries; (d) emotional stress, and (e) a deterioration of working conditions, possibly leading to less retention (Seavey, 2018). The direct and indirect average turnover cost estimate is significant at $3,500 per PCA (Seavey, 2018). Patient care assistant retention impacts hospitals on many levels, and these organizations would benefit from innovative strategies to improve retention. Literature Review June 2024 | Volume 3, Number 2 4 The COVID-19 pandemic has had a profound impact on healthcare systems worldwide, and one of the critical challenges that emerged during this time was PCA retention (Falatah, 2021). PCAs played a pivotal role in caring for patients affected by the virus, often working long hours under extreme pressure, and facing high risks of exposure. The immense demands and stressors experienced during the pandemic have increased burnout rates and decreased job satisfaction among PCAs, which pose a significant threat to hospital employee retention (Falatah, 2021). Therefore, it is crucial to address the issue of PCA retention post-pandemic to ensure the availability of a skilled and motivated nursing workforce. PCA retention in hospitals is a pressing issue that needs to be addressed, especially after the COVID-19 pandemic, as PCAs face significant challenges such as burnout and decreased job satisfaction (Lewis, 2023). To mitigate these challenges and promote PCA retention, hospitals should focus on enhancing work environments, implementing support programs, and providing competitive wages. This study explored the factors contributing to PCA retention challenges after the COVID-19 pandemic and proposed strategies that hospitals can implement to improve PCA retention. Employee retention has been one of the most escalating concepts in hospitals in the last decades and during the pandemic (Mueller et al., 2010). PCAs are valuable assets for hospitals and could be labeled as the lifeblood of an organization (Jones et al., 2018). Especially in pandemic times, PCAs, strategic assets of any hospital, should be managed, preserved, and retained with experience and skills in focus when they feel stressed and dissatisfied with their current job role because of associated factors (Falatah, 2021). In this study, the researcher reviewed articles published by the Society of Human Resources, including peer-reviewed articles, to explore the phenomenon of PCA retention in hospitals after the COVID-19 pandemic. A qualitative study examined human resources strategies to retain PCA in hospitals in the Midwest region of Ohio. Herzberg's two-factor motivation theory was used in this literature review so the researcher can assess factors that motivate employees. The COVID-19 pandemic has resulted in several factors contributing to the challenges of PCA retention in hospitals. The pandemic placed an immense physical and emotional burden on PCAs (Lewis, 2023). PCAs faced increased workloads, long hours, and high-stress environments, which led to burnout and exhaustion (Lewis, 2023). The constant exposure to the virus also created fear and anxiety among healthcare professionals, including PCAs, which further impacted their overall well-being. The pandemic highlighted existing PCA shortages in healthcare (Lewis, 2023). Many hospitals experienced a surge in patient numbers, stretching their resources to the limit (Lewis, 2023). This shortage of PCA staff created a demanding and unsustainable work environment, causing PCAs to reconsider their commitment to their profession (Lewis, 2023). Additionally, the pandemic exposed structural issues in healthcare systems, such as inadequate support, limited resources, and insufficient compensation, all of which contributed to PCA dissatisfaction and increased turnover rates (Lewis, 2023). Theoretical Foundations The researcher used Herzberg's two-factor motivation theory for the study's framework (Hines, 1973). Herzberg's two-factor motivation theory allowed the researcher to investigate factors that motivate employees (Hines, 1973). The research explored factors that affected PCA retention after the COVID-19 pandemic and what HR leaders can do to retain PCA in the hospital setting. Herzberg's two-factor motivation theory was examined in the first section of the literature review so that the research could further examine the framework of the study. The literature review examined the causes of low PCA retention in hospitals in the Midwest. The researcher compared Herzberg's two- factor motivation theory and the expectancy theory of motivation. In comparing both theories in the pieces of literature, the researcher noted the following observations: (a) workplace burnout, (b) compensation, (c) advancement opportunities, and (d) PCA-to-patient ratios. Herzberg's Two-Factor Motivation Theory The researcher used Herzberg's two-factor motivation theory to support their conceptual framework. Fredrick Herzberg created the theory in 1959 (Herzberg, 2003). Herzberg suggested that factors that lead to job satisfaction and dissatisfaction are different (Herzberg, 2003). According to the theory, factors related to job content, such as autonomy, challenge, and opportunity to learn and grow, are generally referred to as intrinsic factors or motivators that produce job satisfaction and, therefore, the motivation to perform (Herzberg, 2003). Factors related to the job Business Management Research & Applications: A Cross-Disciplinary Journal 5 context, such as a safe work environment, pay, compensation package, and supervision, are generally referred to as extrinsic factors or hygiene factors, which do not produce job satisfaction and, therefore, do not motivate performance. Still, their absence is dissatisfying (Herzberg, 2003). Vroom Expectancy Theory of Motivation Vroom (1964) developed the expectancy theory of motivation. Vroom's (1964) theory is based on organizational behavior and how it motivates employees (Steele, 1964). Expectancy theory proposes that motivation is highest when individuals believe that their efforts will result in a desirable outcome and that this outcome is attainable through their actions (Steele, 1964). In other words, if an individual believes that their efforts will lead to success and that success will result in a desirable outcome, they will be highly motivated to perform the task. This theory has important implications for understanding the motivation process because it highlights the importance of goal setting, feedback, and rewards in motivating individuals (Steele, 1964). The theory also suggests that when individuals set specific, challenging goals and receive feedback on their progress toward them, they are more likely to be motivated to continue working toward them (Steele, 1964). Additionally, when individuals receive rewards or positive outcomes for their efforts, they are more likely to be motivated to repeat the behavior in the future (Steele, 1964). Overall, the expectancy theory of motivation is a helpful framework for understanding how individuals decide their behavior and what motivates them to act. It emphasizes the importance of goal setting, feedback, and rewards in promoting motivation and can be applied in various settings to increase performance and productivity (Steele, 1964). Review of the Literature The COVID-19 pandemic has had a significant impact on the PCA workplace, and as a result, many researchers have examined PCA retention considering these changes (Lewis, 2023). While there is no single way to study PCA retention, there are some strengths and weaknesses to other researchers' approaches (Lewis et al., 2022). According to a study by Renaud et al. (2017), a longitudinal design was used for PCA retention after COVID-19. By following the same group of PCAs over time, Renaud et al. (2017) could better understand how PCA retention has changed in response to the pandemic (Renaud et al., 2017). PCA Shortage in Midwest Ohio Midwest hospitals saw an increase in the PCA-to-patient ratio due to the shortage after the COVID-19 pandemic (Falatah, 2021). Due to staffing issues, PCAs encounter long work hours and less time off. After the COVID-19 pandemic, PCAs re-evaluated their decisions to pursue other hospital opportunities. Many hospitals in the Midwest of Ohio face more safety concerns, the overwhelming number of patients being seen in emergencies, and the high risk of healthcare-acquired infections (Donnely, 2022). The situation in Midwest Ohio hospitals reflects a national phenomenon, and the shortage is of great concern to many because it compromises access to quality patient care (Donnely, 2022). PCAs play an intricate role in healthcare. PCAs help patients with hygiene, assist the patient in daily activities, take vital signs, and monitor general health conditions. Shortly after the COVID-19 pandemic, retention approaches in healthcare organizations often focused on short-term solutions, such as offering employee incentives or bonuses, rather than addressing the root causes of PCA retention (Falatah, 2021). This has led to a lack of sustainability in retention efforts and an inability to retain PCAs long-term (Falatah, 2021). Other problems with PCA retention approaches may include a lack of focus on PCA development, inadequate communication, and a lack of support for work-life balance (Falatah, 2021). Causes of Shortage After the COVID-19 Pandemic in Midwest Ohio The COVID-19 pandemic has highlighted the many issues facing PCAs and the US healthcare system (Donnely, 2022). The nationwide PCA shortage is essential to this study, though it is a complex issue. While the PCA June 2024 | Volume 3, Number 2 6 shortage undoubtedly affects critical and emergency care, it is felt across all clinical settings, including long-term care (Donnely, 2022). The PCA shortage predates the pandemic (Needleman et al., 2011). The pandemic's additional pressures, workload, and stress have exacerbated the situation. Many PCAs are leaving the profession, reporting poor working conditions and an increased psychological burden (Seavey, 2018). The PCA profession faces shortages due to a lack of potential preceptors, high turnover, and inequitable workforce distribution. The causes of the PCA shortage are numerous and cause issues of concern (Donnely, 2022). Compensation As that need grows, the labor force has not kept up with demand. The Federal Bureau of Labor Statistics projects that by 2030, there will be nearly 600,000 open positions nationwide, or a 32.6% increase from 2020, including nearly 40,000 in Ohio (Ohmart, 2022). The average annual wage for PCA in Ohio was $27,870, or about $13.40 an hour, as of May 2021 (Ohmart, 2022). PCA compensation remains a challenge for healthcare (Donnely, 2022). The Nation Association of Health Care Assistants reports low wages and benefits as the primary reason PCAs leave the workforce (Ohmart, 2022). Ohmart (2022) states other factors include burnout and a lack of respect from leadership (Ohmart, 2022). PCA compensation must be addressed before the shortage becomes a crisis (Donnely, 2022). After the COVID-19 pandemic, states such as Michigan have put together tactics to mitigate low wages for PCAs (Hurst, 2002). Such as being offered a $2.35 increase per hour. When researching the average PCA pay in Ohio, it is evident that pay is low. P.C.A.s. However, this tactic was only available to those facilities that were nursing homes and participated in either Medicaid or Medicare pass-through payments (Donnely, 2022). Hospitals were not offered this tactic, so these organizations struggled with PCA retention even though high census pay and incentive pay were being offered by the hospitals in Midwest Ohio (Chin, 2022). PCA Burnout During the pandemic, PCAs had hectic working hours due to the increasing number of COVID-19-positive cases and increased inpatient admissions, contributing to PCA burnout during the COVID-19 pandemic (Carayon & Gurses, 2005). The PCA shortage has a tangible impact on PCAs' working conditions. Growing workloads erode PCAs' ability to provide the care they feel their patients deserve (Carayon & Gurses, 2005). This inner tension can create a heavy psychological burden. (Carayon & Gurses, 2005). PCA burnout is a deleterious and consequential syndrome that affects not only the individuals but also the organization and patients in which those PCAs labor (Ohmart, 2022). As many as half of the PCA workforce is experiencing burnout, with the likelihood of personal consequences, job dysfunction, and potential risk to patients (Ohmart, 2022). During the COVID-19 pandemic, the media has rightly focused on how burnout impacts healthcare workers (Falatah, 2021). During this period of acute stress, the prevalence of burnout is expected to rise (Falatah, 2021). However, even pre-pandemic, PCAs were showing alarming rates of burnout symptoms. This points to longstanding issues with PCAs' working conditions, where prolonged stress and heavy workloads were already endemic (Falatah, 2021). PCA-to-Patient Ratios During the COVID-19 pandemic, the issue of PCA burnout has become even more pressing due to the increased demands placed on healthcare systems (Duffield et al., 2009). PCAs have been working long hours, often without adequate support or resources, which can exacerbate burnout (Carayon & Gurses, 2005). Needleman (2011) found that PCAs working during the pandemic reported higher burnout levels than before the pandemic, with increased workload and insufficient staffing cited as key contributing factors. Research on the relationship between PCA-to- patient ratios and burnout during the pandemic is still emerging (Weydt, 2009). However, Seavey (2018) found that PCAs working in higher patient-to-PCA ratio units during the pandemic reported higher levels of burnout. This suggests that even during a crisis such as the COVID-19 pandemic, PCA-to-patient ratios remain an important factor in PCA levels of burnout. While the relationship between PCA burnout and PCA-to-patient ratios is complex and multifactorial, there is evidence to suggest that higher PCA-to-patient ratios can contribute to burnout among PCAs Business Management Research & Applications: A Cross-Disciplinary Journal 7 both before and during the COVID-19 pandemic (Ohmart, 2022). Healthcare systems need to prioritize safe staffing levels and provide adequate support and resources for PCA to prevent burnout and promote well-being (Ohmart, 2022). Methods The problem explored in this study was retention among PCA staff during and after the COVID-19 pandemic in hospitals in Midwest Ohio. Thus, this qualitative pragmatic inquiry study explores strategies to retain PCAs during and after the COVID-19 pandemic in hospitals. The study's target population comprised eight department managers, two human resource business partners, two human resources directors, and one Chief Human Resource Officer at a level-one, 145-bed trauma hospital in the Midwest. These participants were selected because each was on the front lines during and after the COVID-19 pandemic. The human resources business partners contributed to turnover data and retention changes, work-life balance, emotional support, and employee health and wellness for PCAs. The human resources directors contributed to the organizational strategies to retain PCAs, and the Chief Human Resources Officer contributed to how these retention strategies were developed and executed. All participants contribute their professional opinions based on five years or more of on-the-job experience and five years or more in leadership. The following research question was developed to understand the retention strategies used for PCA retention: RQ1: What strategies do HR leaders and managers use to retain their PCA staff during and after the COVID-19 pandemic? Data Collection and Analysis Procedures The researcher investigated strategies to retain PCAs during and after the COVID-19 pandemic in a Midwest hospital. Participant interviews were used as the data collection method, and the target population consisted of (a) managers, (b) human resources business partners, (c) human resources directors, and (d) a chief human resources officer with at least two years of experience in leadership and employed during and after the Covid-19. The researcher used purposive sampling for this study. Purposive sampling allowed the researcher to focus on relatively small samples in-depth and gather qualitative responses, which led to better insight and ensured the sample represented the population of interest. (Podvin, 2022). The researcher discovered the three themes: (a) PCA compensation, (b) PCA burnout, and (c) PCA-to-patient ratios. The researcher sent a total of one hundred and thirty surveys. Out of a hundred and thirty surveys, seventy-one managers reported to have at least two years of experience, nine HR leaders reported to have at least two years of experience, one hundred and six employees reported they were employed during and after the pandemic, and ninety- eight employees reported they were full-time. The researcher then sent 30 emails to participants that met the study benchmark. The researcher received 17 emails from participants who declined to participate in the study, and 13 participants responded that they were interested in participating. The researcher sent the 13 participants signed consent forms, which were signed and emailed back to the researcher within two weeks. The researcher interviewed 13 participants and conducted these interviews on-site at the facility. Due to time restraints, the researcher conducted four interviews via MS Teams in a private setting or office. The researcher received signed informed consent from each participant and advised that a voice recorder would be used to capture the data for accuracy. The researcher made sure that participants were free from distractions and interruptions by viewing the participants' work areas. After completing the interviews, the researcher resighted the interview questions and answers verbatim to Google Doc Voice Typing to begin applying codes to exceptions. To maintain the participants' privacy, the researcher used the following naming references: M1, M2, M3, M4, M5, M6, M7, M8, H9, H10, H11, H12, and H13. Microsoft Word was used to present the data, and Microsoft Excel was used to chart the commonality of the data. June 2024 | Volume 3, Number 2 8 Results As a reminder, the following research question was developed to understand the strategies used for PCA retention: RQ1: What strategies do HR leaders and managers use to retain their PCA staff during and after the COVID-19 pandemic? Theme 1: PCA Compensation PCAs are vital to healthcare, and compensation drives retention (Chin, 2022). The relationship between compensation and PCA retention indicates that an effective compensation package has a positive relationship with PCA retention and thus affects a PCA's decision to stay with the organization (Chin, 2022). All 13 participants reported that PCA salary directly impacted PCA retention during and after the COVID-19 pandemic. P4 and P8 stated that PCA compensation and retention are closely connected because PCAs would have stayed longer with the organization if they felt fairly compensated for their work. H9 and H10 indicated that a well-designed compensation package with competitive salaries, benefits, and bonuses can motivate PCAs to stay with the organization and contribute to its success. In contrast, H12 and M4 noted that a compensation package that is not competitive can make employees feel undervalued and underappreciated, which can lead to low morale and high turnover rates. H12 and M4 also noted that the organization was competitive in pay for one area with a similar job PCA description. However, H13 stated that compensation is not the only factor that impacts PCA retention. Other factors influencing PCA employees' decisions to stay with a company include opportunities for growth and development. H13 continued to state that PCAs want to feel they are growing and developing in their careers. Providing opportunities for training, development, and advancement can help retain talented PCAs. H12 noted that an organization's culture can significantly influence PCA retention. Moreover, a positive, inclusive, and supportive culture can create a sense of belonging and loyalty among PCAs. According to H10 and M6, the relationship between compensation and performance appraisal was also related to PCA retention. The participants noted that the relationship between compensation and performance appraisal is crucial because it links a PCA's performance to its compensation. Performance appraisals evaluate a PCA's job performance and determine appropriate compensation, including salary increases, bonuses, or promotions. H11 reported that since organizations determine compensation based on job responsibilities, market rates, employee performance, and internal equity, offering incentives and bonuses during and after the COVID-19 pandemic would increase PCA retention. M3 and M7 noted that when PCAs feel satisfied and connected to their workplace, they are more likely to stay with the company for the long term. A positive culture can also be a competitive advantage in retaining PCA's talent. Organizations with reputations for being great workplaces are more likely to attract skilled and motivated PCAs who want to be part of that culture. An inclusive and open culture can encourage innovation and creativity. When PCAs feel comfortable sharing their ideas and are free to experiment, it can lead to developing new services and processes, contributing to the organization's growth. Moreover, a culture that promotes collaboration and teamwork can lead to more effective communication and problem-solving. When PCAs work well together, it can enhance overall efficiency and the quality of work produced. H9 noted that PCAs are in high demand, and leaders can impact change through compensation. As noted, compensation is not the only factor that impacts PCA retention. Organizational culture, benefits, job satisfaction, and evaluation of performance appraisals are other factors contributing to PCA retention. Equitable Compensation Business Management Research & Applications: A Cross-Disciplinary Journal 9 H11 noted that pay is equally essential to the PCAs and the organization. An organization's compensation program is strongly related to the organization's financial performance. During and after the COVID-19 pandemic, the organization was struggling financially. However, PCAs still wanted to know they were valued for their time, effort, and performance. The amount of pay and benefits during and after the COVID-19 pandemic could have motivated the PCAs and their direct behavior to retain them throughout the pandemic. Compensation plays a vital role in an organization's retaining and attracting high-performance PCAs. On the other hand, the cost of compensation also plays an essential role in the success of an organization. Theme 2: PCA Burnout H9 and H11 noted that to empower PCAs and foster a healthy work environment, leadership is seen as a crucial component. The participants also noted that managers play a major role in preventing PCA burnout because they can create a friendly environment so PCAs feel safe and easily complete their work. The manager should have leadership qualities to achieve positive outcomes. H10 and H13 stated that during the pandemic, the PCAs had hectic working hours due to the increasing number of COVID-19-positive cases, increased inpatient admissions, working long hours, staying away from families, working in high-risk areas, inadequate availability of PPE kits, and wearing personal protective equipment while handling patients, which also contributed to PCA burnout during the COVID-19 pandemic. However, this could have been prevented by allowing PCAs to take a one-hour break during their shift. M5 and M6 also noted that taking breaks was not always at the center of attention because of patient care and low PCA retention. Unit managers were trying to manage breaks; however, this was difficult to manage during and after the COVID-19 pandemic. M5 and M6 agreed that breaks would enable PCAs to remove their PPE (personal care equipment) and enjoy their lunches, allowing for more work efficiency. Moreover, provide a 14-day quarantine break to PCAs who work during the COVID-19 pandemic. The hospital administration gives insurance coverage or free services to all the PCAs affected by the COVID-19 pandemic. Manager Involvement The researcher discovered throughout the study that manager involvement with PCA during and after the COVID-19 pandemic played an essential role in PCA burnout. A deficiency in manager support, including inadequate staffing, limited opportunities for professional development, and a lack of recognition for their hard work and dedication, exacerbated feelings of burnout among PCAs (Cottrell et al., 2023). M6 noted that monitoring workloads, leading by example, and PCA feedback are all strategies that can prevent PCA feedback during another pandemic. PCAs should have been given work based on their strengths, which can be done within the time limit with no difficulties. Organizations or leaders must ensure they are not given unreasonable tasks to do. H10, H11, H12, and H13 noted that managers set examples for the employees working under them. Managers avoided PCA workloads during and after the COVID-19 pandemic because of PCA staffing issues. Managers also neglected manager feedback to PCAs, as this was another cause for PCA burnout during and after the COVID-19 pandemic. Theme 3: PCA-to-Patient Ratios H11 and H12 noted that to ensure safe PCA-to-patient ratios, it is the responsibility of nurse managers to ensure that PCAs maintain appropriate ratios of patients. Managers can convey to senior management the significance of having a suitable number of PCAs on the unit. Moreover, managers must assign PCAs based on the severity of patients' conditions and the work that must be done. This ensures that patients receive the proper care without putting undue stress on PCAs. H10 and H13 noted that managers performing routine checks on patient ratios and PCA workloads can detect and resolve problems as quickly as possible. This may include altering the staffing levels or shifting resources per the requirements. H9 noted that managers should offer training, direction, and support to PCAs, enabling them PCAs to handle their tremendous workloads and maintain a high level of patient care more successfully. Moreover, nurse managers are responsible for facilitating communication among PCAs and encouraging open discourse regarding staffing and safety issues. June 2024 | Volume 3, Number 2 10 Recommendations The main research question examined what strategies HR leaders and unit managers use to retain their PCA staff during and after the COVID-19 pandemic. Participants identified several factors that led to PCA turnover during and after the COVID-19 pandemic. The findings suggest that PCAs often face heavy workloads, long hours, low wages, high stress, fatigue, workplace violence, and harassment. These factors affected job satisfaction, productivity, health, and well-being during and after the COVID-19 pandemic, leading PCAs to leave the profession. The pandemic escalated work demands on PCAs significantly. PCAs faced longer shifts, increased patient loads, and emotionally taxing situations due to the high influx of COVID-19 patients. This overload led to physical and emotional exhaustion, contributing to burnout. Participants noted that PCAs had to deal with the overwhelming demands of patient care during the pandemic, coupled with the fear of contracting the virus and heightened stress levels among PCAs. Constant exposure to such stressors and exhaustion increased the likelihood of burnout and made the work environment less sustainable. Moreover, PCAs faced hostility or harassment due to misinformation or fear around the pandemic. Instances of violence or mistreatment from patients, families, or even within the workplace created an unsafe and hostile environment, contributing to PCAs' decision to leave. PCA Compensation Participants noted that compensation played a significant role in PCA retention. PCAs felt they were not being paid or compensated fairly, so they sought employment opportunities that offered better compensation and benefits. The unit managers identified that during the COVID-19 pandemic, there was a shortage in many regions because of the abrupt increase in demand for PCA professionals. The organization found it difficult to give above-market pay to add PCAs because of financial limitations or pre-existing pay structures. Participants also noted that the increasing costs for medical supplies, PPE, and infrastructure upgrades put a financial burden on the organization and made it difficult to allocate money for higher compensation. According to Herzberg (2003), pay is pointed out as a hygiene factor (Herzberg, 2003). The findings suggest that increasing pay can motivate PCAs, especially if they feel that their current pay is not commensurate with the patient care they are giving. Each participant recognized that PCAs would perform better during times of crisis if compensation was above market value and additional pay incentives were given. The findings suggest that conducting several market analyses, offering flexible compensation packages, investing in retention strategies, advocating for policies, building contingency funds, and adopting technology for efficiency throughout a pandemic will allow the organization to determine the above-market wage rate for PCAs. This will ensure that the organization is offering crisis pay competitively to the industry, thus reducing PCA turnover and increasing PCA retention due to a pandemic. Moreover, the researchers suggest that HR leaders should consider offering additional incentives such as bonuses and crisis pay, which can reward employees for their work and the organization's shortcomings. Recognition and Rewards The finding suggests that before the COVID-19 pandemic, PCAs felt valued, supported, and motivated to grow and develop in their careers. This was essential for the PCA's job satisfaction and overall success (Hines, 1973). Participants identified that PCAs were not recognized and appreciated to the extent they deserved during and after the COVID-19 pandemic due to the increased workload, limited resources, and societal unawareness of their contributions. The findings suggest that HR leaders can implement strategies such as regular acknowledgment and gratitude, providing emotional and mental support, offering professional development opportunities, and ensuring competitive compensation and benefits. The researcher's findings can also help the organization develop strategies to assist with recognition programs celebrating certifications, successful patient outcomes, or innovative practices. PCA recognition programs, such as the PCA of the Month awards, highlight outstanding performance and inspire others, creating a positive and supportive work environment. These efforts will help recognize and appreciate PCA's hard work during another pandemic, improving their job satisfaction and well-being. Career Advancement Business Management Research & Applications: A Cross-Disciplinary Journal 11 Participants noted the organization needs to facilitate continuous education and training by organizing workshops, seminars, and training sessions on the latest medical technologies and best practices. Moreover, financial support in the form of tuition reimbursement programs can be offered to PCAs who wish to pursue advanced degrees or certifications. By investing in their education, the organization enhances the PCA's skills and improves the quality of patient care (Hassan, 2022). PCA Burnout Participants identified that the surge in COVID-19 cases led to an overwhelming increase in patient load, creating a demand for more PCA professionals. PCAs often work long hours with limited time for breaks or days off. Many units experienced PCA shortages due to illness, quarantine measures, or increased demand. This put additional pressure on the existing PCAs to cover shifts and increased their workload. HR leaders and unit managers can implement several strategies to foster work-life balance for PCAs during another pandemic or crisis. The researcher's findings suggest providing flexible scheduling options to accommodate the diverse needs of PCAs. These options could include part-time options, job-sharing arrangements, and possible opportunities for remote work. The findings also suggested that unit managers should develop robust staffing plans that consider potential fluctuations in demand. Implement contingency measures to address PCA shortages, such as cross-training and the ability to bring in additional temporary PCA staff during emergencies. PCA-to-Patient Ratio Participants identified that the COVID-19 pandemic posed unprecedented challenges, diverting attention and resources from routine healthcare operations. Monitoring PCA-to-patient ratios became challenging due to overwhelmed healthcare systems and urgent demands. The findings suggest that unit managers should enhance preparedness for future pandemics by implementing robust monitoring systems, utilizing technology for real-time data, and establishing clear communication channels to address PCA staffing issues promptly. The participants also noted that utilizing advanced technology to establish real-time monitoring systems that provide instant updates on PCA-to-patient ratios, employing data analytics to predict potential surges in patient numbers, allowing proactive adjustments to staffing levels, developing flexible staffing models that can quickly adapt to changing circumstances, such as cross-training staff to handle different roles, and establishing comprehensive contingency plans that outline specific steps to be taken in the event of a pandemic can address PCA ratios during another pandemic. Recommendations for Future Research The first recommendation is to advocate for a future qualitative inquiry study that includes PCAs and excludes leadership positions. Investigating the PCAs' views and thoughts on how the COVID-19 pandemic shifted their trajectory will allow for the implementation of different strategies to retain PCAs. PCAs can provide a contrasting view and supplement the researcher's current findings. P.C.A.s are cornerstone players, and their views and opinions can aid in developing different strategies not currently employed in healthcare. The second recommendation can include PCAs in the research to analyze their chief complaint about how the COVID-19 pandemic impacted their lives, their reasons for leaving, their effects on PCA-to-patient ratios, burnout, and compensation. The study results could provide a different viewpoint and aspect of the findings. Lastly, obtaining the perceptions of the PCA can lead to evolving retention tactics that are not currently in place. The third recommendation is to include PCAs in the research to analyze how communication played a role during and after the COVID-19 pandemic. The study's results could reveal how changes in communication between management and the organization affected their perception of the organization they worked for. The PCA point of view would allow the organization to make changes that are taking place during times of a pandemic and allow the organization to achieve maximum communication goals. It is possible to close the gap in PCA retention during a pandemic, but to close this gap, research will have to be an ongoing task. This study highlighted the intrinsic and extrinsic roles that play a part in PCA retention. PCAs should June 2024 | Volume 3, Number 2 12 be appreciated for their hard work. They should be recognized and rewarded for their work to stay motivated and improve their performance. Empowering PCAs and considering their ideas in the decision-making process will make their voices heard by the organization. Once they feel empowered, their productivity and commitment will increase. Recommendations for Practice The recommendations for this qualitative inquiry study result from data analysis from semi-structured interviews with participants from a hospital in Midwest Ohio. The recommendations may help implement strategies to retain PCAs during and after another pandemic and reduce PCA turnover during another pandemic. 1. The researchers first recommend that HR leaders provide above-market compensation packages during and after a pandemic, which is vital when retaining PCAs. A practical market analysis during the pandemic can lead to higher retention of PCAs. Market analyses during a pandemic can allow the organization to compare its wages and adjust accordingly. Also, provide crises and pay incentives during these times. This will ensure that PCAs are retained and that they are being paid for working in hazardous work environments. 2. The researchers' second recommendation was that the participants recommend that unit managers provide safe PCA-to-patient ratios. PCA-to-patient ratios play a vital role in patient care and patient satisfaction. When the ratios are too high, it can result in overworked and stressed PCAs, leading to burnout and job dissatisfaction. In contrast, when the ratios are reasonable, PCAs provide better care, feel more satisfied with their jobs, and are likelier to stay in their positions. Adequate staffing levels that allow for a reasonable PCA-to-patient ratio are critical for ensuring PCAs can provide high-quality patient care and maintain a manageable workload. By monitoring acuity during pandemic times, unit managers must prioritize staffing levels and PCA-to-patient ratios to support their PCA staff's well-being and job satisfaction. 3. The researchers' third recommendation is that HR leaders and unit managers must implement a plan for PCA work-life balance during and after another pandemic. This can include implementing work-life balance strategies. This recommendation's first line of defense is for managers to recognize when their PCAs are burned out. Managers can spot increasing error rates, absenteeism, and signs of stress-related burnout more easily than anyone else in the organization. Implementing employee assistance programs, seminars on work-life balance, flex scheduling, job sharing, and encouraging the use of vacation and sick leave time. Moreover, during times before and after a pandemic, healthcare organizations need to promote their work-life balance policies year-round, not just in PCA orientations and handbooks. Lastly, frequent positive communication of these benefits. Conclusion Retaining PCA during another pandemic is essential for the healthcare industry. PCAs provide basic services to patients and assist nursing staff with vitals, maintaining patient hygiene, and listening to patients regarding their health concerns (Jones et al., 2018). Moreover, retaining PCA is essential to patient care and patient quality. The researcher found that when HR leaders and unit managers change (a) PCA-to-patient ratio, (b) pay, and (c) PCA burnout, retaining PCA during another pandemic will be successful. Each HR leader and unit manager recognized that extrinsic and intrinsic motivators are crucial for the organization, as these factors help to improve PCA performance, productivity, and job satisfaction. Each HR leader and unit manager also recognized that while extrinsic motivators, such as bonuses or crisis pay, can also be effective methods, these are often short-term and can lead to decreased intrinsic motivation. Furthermore, HR leaders and unit managers indicated it is necessary to use intrinsic and extrinsic motivators because they complement each other. Extrinsic motivators can help provide short- term rewards and recognition for PCAs, while intrinsic motivators can create a sense of fulfillment and purpose in their work (Cottrell et al., 2023). Retention strategies can be successfully implemented by working closely with HR and management to identify ways to implement these initiatives that work within the organization's budget. The participants in this qualitative inquiry Business Management Research & Applications: A Cross-Disciplinary Journal 13 study provided strategies to retain PCAs during another pandemic. For example, implementing a post-COVID-19 survey allows the organization to find out what PCAs learned and what resources they will need from the organization if another pandemic arises. These surveys can reflect on past PCA retention issues during and after the COVID-19 pandemic and give insight into what an organization needs to do to retain PCA during these times. Other strategies the participants noted were offering flexible work hours, part-time options, or job-sharing arrangements to support PCAs in balancing their work and personal lives. This flexibility enables PCAs to pursue further education, attend training programs, or achieve a healthier work-life balance. Moreover, other HR leaders and unit managers can utilize these strategies. References American Health Care Association. (2022). AHCA survey: nursing staff vacancy and retention in hospital. 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