Recruitment and Retention of SLPs in Health Care

A Guide for Administrators, Program Directors, and Recruiters

• Introduction
• Current Status of SLP Employment
• Retention vs. Recruitment
• SLPs' Prioritization of Job Satisfaction Factors
• Recruitment and Retention Strategies
• Home Care Recruitment and Retention
• Hospital Considerations
• Outpatient Facility Considerations
• Skilled Nursing Facility Considerations
• Appendix

Introduction

Speech-language pathologists (SLPs) are essential professionals in every health care setting-acute care, rehabilitation, pediatric, and psychiatric hospitals; long term care; outpatient facilities; and home health. Their expertise provides invaluable benefit to patients and other staff in managing problems (swallowing, communication, and cognitive-linguistic disorders) that affect patients' overall health, well-being, and ability to benefit from other medical or rehabilitation interventions. The qualifications and expertise of SLPs in health care settings cannot be duplicated by members of other professions. The following information has been developed to assist program directors and administrators in recruiting and retaining a highly qualified SLP staff.

Competition for employing SLPs is anticipated to grow as the demand for SLPs increases due to national demographic and health factors. According to the U.S. Bureau of Labor Statistics (BLS), the employment rate of SLPs is expected to experience "faster than average growth" through the year 2020. The BLS monitors the supply and demand for more than 700 occupations. According to the BLS, more than 28,000 additional SLPs will be needed to fill the demand between 2010 and 2020, a 23% increase in job openings. 

 BLS data retrieved from http://www.bls.gov/ooh/Healthcare/Speech-language-pathologists.htm on May 29, 2012.

Current Status of SLP Employment in Health Care Settings

According to 2011 ASHA membership counts, 38% of certified speech-language pathologists are employed in health care settings. The distribution across settings is as follows:

Employment and Vacancies in Health Care Facilities

ASHA collects data every two years from SLPs employed in health care settings. Information regarding trends in employment status (full- or part-time) and vacancies can be found in the Workforce Trends report.

See all data related to service provision in health care settings.

Benefits

According to the 2011 ASHA SLP Health Care Survey, the largest percentages of respondents reporting paid vacation, paid sick leave, and health insurance benefits were found in the following settings: general medical hospitals, rehabilitations, pediatric hospitals, and skilled nursing facilities. Lesser percentages were reported for home health and outpatient or speech/hearing clinics.

Skilled nursing facilities and outpatient or speech/hearing clinics were more likely to provide ASHA dues, state association dues, and licensure fees than were those employed in hospital settings.

Rehabilitation hospitals, pediatric hospitals, and skilled nursing facilities were more likely to provide continuing education than were the other settings. Rehabilitation, pediatric, and general medical hospitals were the most likely to provide retirement plans while home health was the least likely to provide this benefit.

Retention vs. Recruitment

Retention of existing staff has a greater impact on cost and quality factors in providing speech-language pathology (SLP) services than a successful recruiting program. The benefits of successful retention of staff include both cost savings and quality:

Cost saving factors of successful retention programs

• No lost productivity/revenue caused by vacant positions
• Minimization of new staff recruitment costs (advertising, sign-on bonuses, relocation costs)
• Minimization of reduced productivity/revenue for new staff during orientation

Quality factors of successful retention programs

• Increased experience and efficiency in delivering services  
• Increased consistency and compliance with policies and procedures
• Increased leadership and teambuilding

If you experience frequent turnover of SLP staff, consider conducting exit interviews or questionnaires to explore the reasons. It is rare to lose an employee over pay or benefits, which are more often recruitment issues, not retention issues. Some responses that may point to a need to improve your retention efforts are:

• Unreasonable productivity requirements;
• Administrative demands that conflict with professional ethics or clinical judgement (e.g., mandating a prescribed caseload size without regard to appropriateness of patients; treating patients for a predetermined period of time without regard for tolerance level and/or prognosis);
• Lack of administrative support for non-professional activities (copying or preparing materials, patient transport, record keeping);
• Lack of training to meet job requirements;
• Lack of tools to meet job requirements (e.g., assessment and treatment materials, computers, copiers);
• Inadequate staffing to meed caseload needs;
• Lack of compliance or support by other staff for recommendations made by SLPs;
• Too much travel between patients or facilities; and
• Too much paperwork.

Even a successful recruitment program cannot compensate for the impact of high turnover on the quality, morale, and costs of an SLP staff.

SLPs' Prioritization of Job Satisfaction Factors

The 2011 Membership Survey asked members to indicate the three most important factors for accepting or staying in a job. For the purposes of this survey, SLP respondents in health care were categorized as working in a hospital, residential health care (e.g., skilled nursing facilities), or nonresidential health care (e.g., home health and outpatient clinics).

The top three factors were the same for all health care settings:

1. Flexibility to balance life and work
2. Compensation/pay
3. Meaningfulness of job

In addition, benefits (health care, retirement, etc.) and the type of clients/patients were factors that rated high in importance for all three settings. Job security was the least important factor when accepting or staying in a job.

Retention and Recruitment Strategies

Retention Strategies

Facilities that must recruit new staff on a yearly basis or who rely on hiring Clinical Fellows who leave after completing the clinical fellowship should closely examine the factors that lead to high turnover. Such facilities suffer a double impact because low staffing or prolonged vacancies tend to reduce morale of the remaining staff; in addition, word-of-mouth in the community may label the facility as an undesirable work setting because of the awareness of high turnover rate. In contrast, employees who feel supported and positive about their work setting can be strong recruiters for the facility.

The following are ways to enhance recruitment through your staff:

• Encourage staff to participate in community professional activities
  • Attend local professional meetings (discussion groups, etc.)
  • Attend state association meetings
• Develop a relationship with university SLP graduate programs
  • Offer opportunities for volunteer or observation hours at your facility
  • Become a student practicum site (note that staff may need support in terms of reduced productivity or advancement opportunities to obtain recognition for time devoted to student supervision)
  • Offer to speak to graduate students and give them real-world perspective on course work
  • Participate in university job fairs
  • Develop research partnerships
• Increase visibility of your program and staff in the community
• Celebrate "May is Better Hearing and Speech Month"
• Offer free support groups for patients and/or families
• Offer community in-service programs
• Hold health fairs

Mentoring

Anecdotally, the most vulnerable settings for recruitment and retention are those that employ only a single SLP, particularly on a part-time basis. A Clinical Fellow or new clinician is likely to feel overwhelmed by the expectations for clinical expertise, documentation, and decision making. Lack of available mentoring for both clinical and professional issues may result in the clinician moving on quickly if another opportunity presents itself. One model that has been used in multifacility organizations is to hire a SLP mentor/supervisor to travel between buildings and be available by phone and/or e-mail to help the clinician develop new skills and to assist with problem solving and particular clinical challenges. Alternative models are peer mentoring or a buddy system, where SLPs feel that they have somewhere to turn for assistance. Additionally, offering refresher courses or training for transitioning into a new position can be helpful. Having existing Clinical Fellow programs in place can also be useful when hiring Clinical Fellows.

Graduate Student Supervision

Clinicians report many positive aspects about supervising students, including being stimulated to develop their own skills by working with students and staying current in the profession by having a relationship with a university program. Clinicians who have supervised students say that it is a personally rewarding experience and that they enjoy it.

ASHA's SLP Health Care Survey 2007 asked respondents to select the top three incentives that would encourage them to supervise a student. The top responses included:

• Receiving CE credit for supervision (75%)
• Receiving a financial incentive (59%)
• Reduced caseload/productivity requirement (45%)

Overall, respondents to the 2009 Health Care Survey indicated that they supervised, on average, 1 student intern in the previous year. This increased to an overall average of 3 students in 2010 (as reported in the 2011 Health Care Survey). Those in pediatric hospitals supervised the most students, with an average of 5 reported for the year prior to the survey year.

SLPs in home health and skilled nursing facilities (SNFs) do not tend to supervise students as often as those in other settings. This is in part due to the nature of the work involved, particularly travel for home health, and the fact that SLPs in these settings do not always carry full-time caseloads and therefore find having a student challenging. Supervising a student in home health or SNFs is not impossible, however, and may be the only way that a student is made aware of these options as a potential work setting. Collaboration between the SLP and administration is vital to the success of a student supervision program.

Continuing Professional Development

Although salary and benefits are important factors in recruitment and retention, there are many other types of benefits and recognition that may be meaningful to clinicians that do not have as great a financial impact on the organization. Opportunities for continuing education are a significant benefit to SLPs. Many states require continuing professional education for maintenance of licensure, and ASHA requires CEUs for maintenance of certification. Facilities can provide continuing education opportunities that are both a financial and convenience benefit to staff by bringing in speakers, participating in ASHA's telephone seminars (which are available to groups), or purchasing ASHA's self-study products.

Resources and Equipment

Clinicians who feel that their work is supported by administration are more likely to stay with an agency or facility. One way of providing this support is to ensure that the facility is well-equipped with up-to-date materials, assessment tools, and technology. Using outdated tests or games, toys, or other therapy materials that are worn out or no longer fully functional decreases morale and may limit the clinician's ability to provide quality services. In addition, having access to technology, such as computers and the Internet, allows clinicians to research current information about patients and treatment options and provides a means of keeping data and producing professional reports and papers.

Promoting Retention Through Recognition

Management research has shown that different types of recognition and benefits are meaningful to different individuals depending on their individual circumstances and preferences. Managers can enhance retention and job satisfaction by customizing the following opportunities or means of recognition to the individual staff member:

Professional Advancement Opportunities

• Providing in-service programs or presentations
• Supervising students
• Peer mentoring
• Serving on or leading a clinical team
• Serving on or leading an administrative team
• Applying for Clinical Specialty Certification (Specialty Certification enables SLPs and audiologists with advanced knowledge, skills, and experience beyond the Certificate of Clinical Competence to be identified by colleagues, employers, referral and payer sources, and the general public) as a Board Certified Specialist [BCS] in a specific area of clinical practice.)

Personal Recognitions

• Increased flexibility in work schedule
• Public acknowledgement of performance
• "Dress down" days
• Gifts to recognize exceptional performance or customer service
• Support for transportation or parking costs
• Additional leave
• An overall sense that what the clinician is doing is valued by the organization and the people served
• Consideration of the clinician's suggestions and ideas about service provision, scheduling, staffing, etc.

Additional Strategies

No matter how well-managed and happy a staff is at any facility, vacancies will open and new staff will need to be recruited. Management needs to plan how to reach a broad pool of SLPs who may be interested in the position. In addition to local advertising, the following strategies should be considered:

• Word of mouth recruitment (with incentives to current staff for successful hires)
• Graduate programs at universities within the state
• ASHA's website
• ASHA's publication, The ASHA Leader
• Career fair at ASHA's Annual Convention in November
• State speech and hearing association publications and annual meetings

To compete with other facilities, advertising your position might feature the following:

• Unique benefits (continuing education, flexible work hours, job sharing opportunities)
• Unique clinical focus or opportunity of the position
• Sign-on bonuses
• Paid moving expenses
• Reputation of the program or facility

Home Care Recruitment and Retention Considerations

Working in a home health environment presents unique challenges to both the SLP and the administrators trying to recruit them. Documentation requirements are different in home health (OASIS, daily notes) and the very nature of home health requires that an SLP be independent and willing to travel, often many miles each day. Probably one of the greatest challenges for recruitment is the fact that there is often not a full SLP caseload available and agencies may only offer a part-time or PRN position without paid benefits. There are many SLPs working in home health that do so as a "second" job in the evening after working a full day somewhere else.

The 2007 Health Care Survey asked the following question: "What are the greatest challenges you face in health care?" In rank order, respondents from home health/client's home reported the following challenges:

• Paperwork (clinical and reimbursement; 61.7%)
• Insufficient reimbursement (for clinical services; 39.4%)
• Keeping current with advances in clinical information (33.4%)
• Unsatisfactory salary/benefits (22.3%)
• High productivity requirements (22.3%)
• Managing caseloads at multiple sites (20.3%)
• Resources to respond to diversity within caseload (14%)
• Not being valued by other disciplines/administration (12.0%)

In 2009, respondents were asked about undesired changes they had experienced in their work environment over the previous year. This question was asked, in part, because of the challenging economic times. In rank order, respondents from home health/client's homes reported the following:

• None of the above (50%)
• Increase in caseload/workload/productivity (19%)
• Reduction in salary or benefits, without changes in hours (15%)
• Increase in the number of sites served (11%)
• Reduction in work hours (8%)
• Increase in work hours (8%)
• Reduction in caseload/workload/productivity (7%)
• Conversion from salaries to hourly or PRN pay (2%)
• Replacement by support personnel (2%)
• Job loss/layoff (2%)

Hospital Considerations

Working in a hospital environment presents unique challenges to SLPs as well as the administrators trying to recruit them. The nature of both the acute care and rehabilitation hospital settings lends itself to technological advances within the realm of speech, language, voice, and swallowing diagnostics and therapy. Therefore, the hospital-based SLP must be trained and knowledgeable in these areas (i.e., videofluoroscopy, fiberoptic endoscopy examination of swallowing, trach/vent care, etc.). Continuing education is very important for the hospital-based SLP to remain up-to-date on the current diagnostic and treatment trends. Hospitals are also usually fast-paced, active environments that require clinicians to be flexible and organized. In order to succeed, the hospital-based SLP must be vigilant about maintaining timely and accurate clinical documentation and billing records as well as working efficiently to meet productivity targets.

The 2007 SLP Health Care Survey asked the following question: "What are the greatest challenges you face in health care?" Data were collected from SLPs working in both general medical hospitals and rehab hospitals. In rank order, respondents from general medical hospitals reported the following challenges:

1. Paperwork (clinical and reimbursement; 45.7%)
2. High productivity requirements (45.3%)
3. Insufficient reimbursement (for clinical services; 43.1%)
4. Keeping current with advances in clinical information (35.8%)
5. Unsatisfactory salary/benefits (31.5%)
6. Not being valued by other disciplines/administration (30%)
7. Managing caseloads at multiple sites (18%)
8. Resources (e.g., locating, funding interpreters) to respond to diversity within caseload (11%)

In 2009, respondents were asked about undesired changes they had experienced in their work environment over the previous year. This question was asked, in part, because of the challenging economic times. In rank order, respondents from general medical hospitals reported the following:

• None of the above (41%)
• Increase in caseload/workload/productivity (27%)
• Reduction in salary or benefits (without changes in hours) (15%)
• Reduction in caseload/workload/productivity (12%)
• Reduction in work hours (10%)
• Increase in the number of sites served (9%)
• Increase in work hours (7%)
• Conversion from salaries to hourly or PRN pay (4%)
• Job loss/layoff (3%)
• Replacement by support personnel (1%)

Outpatient Facility Considerations

There are unique challenges that come with working in the outpatient setting. The caseload may be more diverse in terms of clients' age and disorders, and may require developing competencies in areas such as voice disorders or pediatric speech and language disorders. In addition, good clinical documentation skills and knowledge of coding for reimbursement are essential. In this setting, the majority of services may be billed to private insurers, requiring preauthorizations, careful tracking of approved visits, and documentation of progress toward functional goals.

Note: The questions below have not been repeated in more recent surveys. This is the most current survey data regarding employment challenges and changes.

The 2007 SLP Health Care Survey asked the following question: "What are the greatest challenges you face in health care?" In rank order, respondents from outpatient settings reported the following challenges:

1. Insufficient reimbursement (for clinical services; 66.3%)
2. Paperwork (clinical and reimbursement; 57.4%)
3. High productivity requirements (35.3%)
4. Keeping current with advances in clinical information (33.4%)
5. Unsatisfactory salary/benefits (21.3%)
6. Not being valued by other disciplines/administration (14.7%)
7. Managing caseloads at multiple sites (13.6%)
8. Resources to respond to diversity within caseload (9.1%)

In 2009, respondents were asked about undesired changes they had experienced in their work environment over the previous year. This question was asked, in part, because of the challenging economic times. In rank order, respondents from outpatient facilities reported the following:

• None of the above (40%)
• Increase in caseload/workload/productivity (23%)
• Reduction in salary or benefits (without changes in hours) (16%)
• Reduction in caseload/workload/productivity (16%)
• Reduction in work hours (11%)
• Increase in work hours (10%)
• Increase in the number of sites served (7%)
• Conversion from salaries to hourly or PRN pay (3%)
• Replacement by support personnel (2%)
• Job loss/layoff (1%)

Skilled Nursing Facility Considerations

SLPs are presented with a varied caseload that has become more acutely ill than in the past. They also face numerous staffing and reimbursement challenges that are unique to this setting.

Note: The questions below have not been repeated in more recent surveys.  This is the most current survey data regarding employment challenges and changes.

The 2007 Health Care Survey asked the following question: "What are the greatest challenges you face in health care?" In rank order, respondents from SNFs reported the following challenges:

1. High productivity requirements (65.4%)
2. Paperwork (clinical and reimbursement) (58.1%)
3. Insufficient reimbursement (for clinical services) (38.2%)
4. Keeping current with advances in clinical information (31.8%)
5. Managing caseloads at multiple sites (29%)
6. Not being valued by other disciplines/administration (24.7%)
7. Unsatisfactory salary/benefits (18.3%)
8. Resources to respond to diversity within caseload (10.3)

In 2009, respondents were asked about undesired changes they had experienced in their work environment over the previous year. This question was asked, in part, because of the challenging economic times. In rank order, respondents from skilled nursing facilities reported the following:

• None of the above (36%)
• Increase in caseload/workload/productivity (32%)
• Increase in the number of sites served (18%)
• Reduction in work hours (13%)
• Reduction in caseload/workload/productivity (12%)
• Reduction in salary or benefits (without changes in hours) (9%)
• Increase in work hours (9%)
• Conversion from salaries to hourly or PRN pay (6%)
• Job loss/layoff (4%)
• Replacement by support personnel (1%)

Appendix

Qualifications Needed to Provide SLP Services in Health Care

Certificate of Clinical Competence
A qualified speech-language pathologist holds a Certificate of Clinical Competence (CCC) from the American Speech-Language-Hearing Association, which requires: 1) a Master's degree from an accredited graduate program; 2) a passing score on the national PRAXIS exam; and 3) completion of a nine-month Clinical Fellowship under the supervision of a certified SLP. 

State Licensure
Most states license speech-language pathologists. Requirements for licensure tend to be comparable, but may not be equivalent, to the qualifications for the Certificate of Clinical Competence. SLPs licensed in other states must apply for licensure in the state in which they are practicing; holding the Certificate of Clinical Competence tends to facilitate more rapid processing of applications for licensure.  

Clinical Fellows
In some states, individuals who have completed their Master's degree and passed the PRAXIS exam may meet state requirements to be licensed on a provisional basis and may be hired to work in health care settings as Clinical Fellows with the required supervision. 

Students
Students pursuing their Master's degree in speech-language pathology are placed in external practicum settings as part of their graduate program requirements. This is an invaluable opportunity to introduce students to the caseloads and procedures typically associated with health care settings, and to potentially recruit students for positions as Clinical Fellows following graduation. Students may not bill or treat patients independently of the supervising SLP. 

Competencies

In addition to meeting the basic requirements of certification and licensure, many health care facilities verify competencies of SLPs in selected areas of practice and procedures. Documentation of competency in the high volume or high risk activities of the professional in a specific setting is required by accrediting bodies such as the Joint Commission on Accreditation of Health Care Organizations (JCAHO). SLPs who have not achieved competency in specific treatment areas (e.g., swallowing disorders, laryngectomy rehabilitation, trach/vent management) or procedures (e.g., performing and interpreting videofluoroscopic studies of swallowing) may need to complete a combination of reading professional literature, continuing professional education, observation, mentoring, and supervised practice before being deemed competent to practice independently in these areas.

If you recruit SLPs from other settings, offering professional development programs will help new staff achieve a higher degree of competence and compliance with practice patterns in the setting and ultimately, a higher level of satisfaction in their employment.