How To Attract and Keep The Best and Brightest Workers in Nursing Homes

Faced with staff turnover rates well over 50%, absenteeism, call-ins, thefts, filing of false worker compensation claims, criminal records, abuse violations, low morale and low job satisfaction, who would want to end up in nursing home as a resident or an employee?

In July 2000 federal health officials concluded that most nursing homes in the United States are understaffed to the point that residents may be endangered. A report to Congress said that understaffing contributes to an increase in bedsores, malnutrition and weight loss in nursing home residents. The recruitment and retention of both nurses and nurse aides is a critical problem that is expected to grow more serious as aging of the population substantially increases, as the nurse workforce itself ages, and as the decreased levels of job satisfaction lead to pursuit of other occupations. With fewer young people choosing nursing as a career and with a turnover rate approaching 100%, there is a shortage of nurse aides and the rapid increase in the 85+ population will dramatically increase the demand.

The low wages, limited benefits and physical demands of the work lead many to look to other employment. For example, in 1999, the average hourly wage for aides working in nursing homes was $8.29, compared to $9.22 for service workers and $15.29 for all workers. Along with service workers, nurse aides are less likely to have employer-provided health insurance or pension coverage than workers in general. Added to this grim picture, nursing homes have one of the highest rates of workplace injury, 13 per 100 employees in 1999 compared to 8 per 100 employees in the construction industry (Scanlon, 2001).

Whatever problem-solving strategy may work is worth trying because of the substantial direct and indirect costs of recruitment, selection, training, overtime, hiring temporary staff, inefficiency, and decrease in morale and productivity.

A recent study placed the cost of recruiting and training alone at $4,000 per new certified nursing assistant (Hoffman, 2001). On average, 67% of nursing home expenses are for staffing (Guillard, 2000). Working “short,” without appropriate mentoring of new recruits who lack experience and knowledge of residents, can affect safety, quality of care, and quality of life for residents and staff. Some long term care providers have had to use the services of staffing agencies and more overtime, which often leads to resentment, poor morale, and even greater retention and recruitment problems. Some rely on recruiting immigrants with nursing skills from other countries to compensate for the lack of local prospects to fill the shortages.

The puzzling question is why, even under present conditions, do some staff members stay for 20 years and others leave almost before they start? For example, despite low salaries and lack of career ladder, involving aides in care planning has been shown to decrease turnover (Banaszak-Holl & Hines, 1996). However, aide involvement in assessments, aide training and workload, case mix severity, payer source mix, and facility size were not significantly related to aide turnover in that study.

Some of the current initiatives intended to improve recruitment and retention are: 1) improved wages and benefits, 2) additional training and opportunities for advancement, and 3) improved employee supports such as empowerment and participation, childcare and transportation, and options for further education (Scanlon, 2001). It is not yet clear whether these initiatives can solve the problem. This article suggests that self-assessment within your own organization may reveal other underlying reasons for retention and turnover.

With changing demographics, changes in resident needs requiring more complex care, and increasing diversity among staff members, nursing facilities should be managing culture change and cultivating its members to meet these new demands. It is worth reviewing your organization’s communication strategies, beginning with the interview.

Interviewing, socializing, identification and Commitment

Newcomers are not passive recipients of attempts to socialize them into the organization. How does the newcomer “learn the ropes?” How do they develop the variety of skills and the “tricks of the trade?” It starts with how the recruit handles himself or herself at a skillfully crafted interview and then how he or she is socialized into the organization by peers. In one facility, the licensed practical nurse (LPN) said, “You must have patience to work here. It stresses you. Many come only for the paycheck.” One example of the importance of recruiting those who share the same values can be found in a facility in Pennsylvania. At its worst it had two thirds of its staff turnover in a year. They reduced that turnover rate to 27% by examining the hiring records and finding that workers with certain personality traits and attitudes were less likely to leave. These traits included compassion, communication skills, ability to cope with death and dying, and ability to handle such unpleasant tasks as bathroom visits and resident hygiene (Deutschman, 2001).

In a survey of new employees, a study found that interactions with peers, senior coworkers, and supervisors were the most important socialization aids in an organization, with peer interactions identified as most important (Zahrly & Tosi, 1989). Peers offer insight into the expected daily life in the organization and serve as role models. Newcomers need to build competence and confidence quickly. Mentors provide the organization’s values and visions in a less formal way. They serve as advisor, friend, helper, teacher and offer encouragement if they are well-chosen. Supervisors offer insights into the formal organization and the best leaders are good role models. One unit coordinator said “We need a fully integrated team with each person filling in as needed to creatively solve problems. We need to accommodate residents’ short attention span. They feel it if routine and activities are not continuous. Frustration is contagious. They act up.”

We often have this common sense vision that orientation and training is the key to recruitment and retention of excellent employees. The assistant director of Alzheimer’s programming at a for-profit chain of homes said new recruits are concrete thinkers - they remember the examples from training but don’t generalize from those examples to other situations. She does mini-inservicing, that amounts to problem solving in place, often using scenarios or role-playing. The process is not a one-way sharing of what newcomers need to know but a two way process of socialization of the newcomers to help them gain commitment and identification with that organization (Pepper, 1995).

Socialization of that newcomer into the organization is not a simple sequential series of acts but includes contributions by both the organization and the newcomer. All staff should work together to look at what is available to achieve the goals of a continuously evolving organization. Administrators must shift their attention to cultivating people, seeing their potential and creating conditions for them to grow. Their leadership role is one of listening and translating the goals so that they are understood by all.

The newcomer must learn to see himself or herself as a member of the organization. They need to shed their old self and adopt a new image that fits the values of the new organization. They actively negotiate meanings with other newcomers and more experienced members. To become a competent group member, the newcomer must develop awareness and appreciation of normal ways of doing and understanding in this organization. What makes this process more difficult is that facilities have been hiring “unemployables” for positions such as certified nursing assistants as well as in dietary and housekeeping staff because of the low unemployment rates over the last few years. Many lack job preparation skills such as commitment, conflict management, problem solving skills, and contingency planning for transportation and day care. Many are single mothers. The human resources manager in a suburban not-for-profit facility said 35% of accidents occurred in the first 60 days of employment so safety has become a major issue. According to one administrator, “These are primarily minorities, often very religious with their family ranking highest priority, the church second, a good time third, and work trailing in the fourth position. “The organization does not address their culture,” she added.

In an interview with the director of vocational training in a “welfare to work” program, he described the participants as chronically long term unemployed with “horrible” attitudes. Their program had them move from welfare to work in three weeks of intensive training. The training stepped backward from resume writing and dressing for success to a holistic approach to the individual, stressing the importance of being a taxpaying responsible citizen. The lead trainer emphasized critical thinking skills, leisure skills, family, motivation, job search, and lifelong learning.

The average participant was 27 years old, had 2.3 children, spent five years on public assistance, had a history of no employment or large gaps of employment, and there was no father figure in the home. In a ten-month period they trained a total of 100 people for “competitive unsupported employment” - with only nine dropping out of the program. One nursing home chain hired 25 and another hired 12. The nursing home industry, in general, hired more than 50,000 welfare recipients in the last three years (Guillard, 2000).

Where Do We Go From Here?

Nursing home leadership has a major role in management of organizational symbolism by what they pay attention to, measure, and control; by their reactions to critical incidents and crises; by deliberate role modeling, teaching, and coaching; by what they reward and give status to; by their criteria for recruitment, selection, and promotion (Schein, 1985). Leaders can make retention a priority by documenting cost. One chain of nursing facilities was able to make dramatic reductions in annual worker compensation claims, from 2000 claims to 85 claims per year four years later, by making safety a priority. The shock of determining the actual costs of turnover may be enough to make it this year’s top priority, if it doesn’t already have this status. This will assist in winning the enthusiastic support from ownership that is necessary to give the program high value. Visible tracking of results can be motivating and a constant reminder.

Some segments in the industry suggest a complete transformation of the work life of the nursing assistant is in order, by developing a clear career path. Integrated Health Systems, a large provider, made retention their first priority and realized a savings of $14 million during a nine-month period. They addressed orientation, mentoring, career growth, recognition, supervision and compensation (Hoffman, 2001). Wage passthroughs are often mentioned, where some portion of the publicly funded reimbursement increase is used to increase wages and benefits for the nurse aide. Would an increase from $10 to $12 an hour solve the problem of turnover? Increased compensation, by itself, will not guarantee committed employees but it will acknowledge and recognize those who have demonstrated the values or the organization.

A 1996 Gallup poll asked what motivated staff members to stay and found that “good health benefits” and “interesting work” ranked highest. In order to cultivate teamwork and cohesiveness, continuous innovation and education is required. Signing bonuses of $1500, recruitment tables set up at super markets, employee appreciation efforts, flexible scheduling, recruitment bonuses, shift differentials, “float” incentives, pay in lieu of benefits, mandating staffing ratios (may not solve the problem if there is a lack of qualified applicants), and a national registry to assure stiffer background checks, are steps that have been tried or recommended. Regulations that allow a facility to withhold the cost of training based on one-year employment, sometimes called a length of service contract, have been suggested. Unfortunately, all these innovations have not yet produced the persuasive outcomes to support their widespread use. Long term care providers in California and New York are actively opposing mandatory staffing ratios, claiming several studies conclude there is no evidence of a correlation between staffing ratios and quality of care (“CA Association” 2001).

Some suggest the creation of a CNA Specialist career level earning higher salaries because it combines leadership tasks with regular resident care responsibilities. NewCourtland Inc. received the 2001 award for innovation for its “Ladder of Opportunity” program, from the American Society on Aging and the National Council on Aging (“NewCourtland” 2001). Others have advised creating cooperatives where frontline workers actually co-own the organization. Staff can borrow money from the agency, paid through payroll deductions, to purchase shares. Staff would then have input into policies and structure, benefit from the profits, are less likely to seek employment elsewhere and more likely to provide top-notch care (“Long term care” 2000).

Others recommend involving all staff from custodian to CNA to CEO, in dementia care mapping to monitor residents’ well being. All levels of staff can analyze the data. This type of program decreased CNA turnover from 38 to five percent in one facility (“Long term care” 2000).

The total environment of the nursing home revolves around the people in the setting, the physical environment, and the goals and policies of the managing organization (Weisman, 1981). Do you want the rigidity of an institutional setting or the balanced control among staff members, administration and residents of a residential setting? There are philosophical differences between “taking care of” residents and encouraging them to do as much as possible for themselves (Wagner, 1994). What are the underlying assumptions and values of your organization?

Change requires effective communication and collaboration, especially considering the differences in individual and cultural values among staff members and leadership. When given increased autonomy and flexibility, both staff members and organizational leadership need to feel comfortable with decisions. Not only do providers and consumers speak different languages, but professional caregivers also have internal communication problems. These diverse groups need to be trained to raise communication issues, clarify those issues and demonstrate the ability to choose communication behaviors that support commitment, integrity, respect, accountability and other organizational values. Leaders need to listen to how others perceive the same situation, assure successful socialization with peers and mentors, and cultivate leadership in others.

Leaders in mature organizations with dysfunctional processes need two characteristics: 1) the emotional strength to be supportive while the organization goes through unlearning processes, and 2) the vision of what they want to be to help the organization evolve by building on strengths and letting the weaknesses atrophy over time (Schein, 1992).