Healthcare organizationeeducation partnerships and career ladder programs for health care workers Janette S. Dill a, * , Emmeline Chuang b , Jennifer C. Morgan c a University of Akron, Sociology Department, Olin Hall 247, Akron, OH 44325-1905, USA b The University of California, Los Angeles, Department of Health Policy and Management, USA c Georgia State University, Gerontology Institute, USA article info Article history: Received 5 April 2013 Received in revised form 15 August 2014 Accepted 8 October 2014 Available online Keywords: Health care workforce Workforce development Career ladders Innovation implementation Frontline health care workers Partnerships Community colleges Fuzzy set qualitative comparative analysis abstract Increasing concerns about quality of care and workforce shortages have motivated health care organi- zations and educational institutions to partner to create career ladders for frontline health care workers. Career ladders reward workers for gains in skills and knowledge and may reduce the costs associated with turnover, improve patient care, and/or address projected shortages of certain nursing and allied health professions. This study examines partnerships between health care and educational organizations in the United States during the design and implementation of career ladder training programs for low- skill workers in health care settings, referred to as frontline health care workers. Mixed methods data from 291 frontline health care workers and 347 key informants (e.g., administrators, instructors, man- agers) collected between 2007 and 2010 were analyzed using both regression and fuzzy-set qualitative comparative analysis (QCA). Results suggest that different combinations of partner characteristics, including having an education leader, employer leader, frontline management support, partnership history, community need, and educational policies, were necessary for high worker career self-efficacy and program satisfaction. Whether a worker received a wage increase, however, was primarily depen- dent on leadership within the health care organization, including having an employer leader and employer implementation policies. Findings suggest that strong partnerships between health care and educational organizations can contribute to the successful implementation of career ladder programs, but workers' ability to earn monetary rewards for program participation depends on the strength of leadership support within the health care organization. © 2014 Elsevier Ltd. All rights reserved. 1. Introduction Workforce shortages and increasing concerns about quality of care have motivated some health care organizations to invest in career ladder programs, which allow workers to progressively gain skills and knowledge while “on the job” (Althauser, 1989). Partici- pating workers can be rewarded with more demanding tasks, higher income, and in some cases, advancement to a new position, e.g., from licensed practical nurse to registered nurse (Fitzgerald, 2006; Goldberger, 2005). In the short term, anticipated benefits of career ladder programs for health care organizations include a better trained workforce and improved recruitment and retention of high-performing staff (Aiken et al., 2009; Cheung and Aiken, 2006). In the long-term, health care organizations hope that such programs will reduce costs associated with turnover, improve pa- tient care, and/or address projected shortages of certain nursing and allied health professions (Custodio et al., 2009; Lerman et al., 2004; Waldman et al., 2004). Although career ladders hold promise for improving workers' skills and addressing workforce shortages (National Fund for Workforce Solutions, 2013), evidence regarding their efficacy in health care remains limited (Ducey, 2009). Part of the challenge is that until recently, U.S. health care organizations have not invested in developing their frontline workers. In health care, frontline health care workers (FLWs) are defined as employees that provide direct care or support services. FLWs have a low threshold to entry (typically a high school degree with little additional training) and relatively low wages (typically under $40,000 per year) (Schindel et al., 2006). Traditionally, FLWs have been viewed as easily replaced (Lepak and Snell, 2002; Tilly, 2011). However, as health care organizations face increased pressure to provide high quality and low cost care, interest in retaining and training these lower- * Corresponding author. University of Akron, Sociology Department, Olin Hall 247, Akron, OH 44313, USA. E-mail address: jdill@uakron.edu (J.S. Dill). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed http://dx.doi.org/10.1016/j.socscimed.2014.10.021 0277-9536/© 2014 Elsevier Ltd. All rights reserved. Social Science & Medicine 122 (2014) 63e71