Creating a Successful Workforce Culture

Few would argue that turnover in long-term care has been out of control for a long time, despite repeated research projects and surveys examining the needs and desires of staff. For decades, the industry has asked: “What satisfies staff in long-term care?” So what is the problem and why does finding and retaining good employees continue to plague the field? We know what employees want, but we do not seem to know how to provide for their needs.

The cost of turnover is high, ranging from $2,200 to $5,000 per employee and as much as 150% of employees’ annual compensation. Real numbers speak volumes. Do you have a problem? If you don’t look, you won’t know. All too often, facilities do not think they have a problem. While consulting in two organizations, we discovered that both had a high number of staff being hired and leaving. The cost of that turnover surprised them. In one facility, the annual projected expense of turnover was approximately $840,000. In the second facility, where the board of directors did not believe there was an issue with staffing, the expenditure was in the neighborhood of $350,000 per year.

This article will explore mechanisms for designing a workplace culture that addresses the concerns and desires of staff while maintaining the organization’s vision and mission. A cost-neutral approach to staff recruitment and retention will be presented as a long-lasting and sustainable solution.

An Organizational Approach

Creating a successful workforce and culture takes an organizational approach that is leadership-driven. Leadership is critical in the recruitment and retention of staff. Leadership comes from the person at the top—the administrator, CEO, executive director, or designee. Without his or her input or blessing, any initiative, program, new approach or attempt at “culture change” will fail.

The leader need not be the facilitator of change. However, if this person is not the change agent, he or she needs to get out of the way and support others in their quest. Moreover, the answer to an organizational transformation is not found in a single program, department, or initiative. It is not simply an overarching philosophy. It must be more concrete, with a global, systematic, organization-wide plan involving leadership and all staff, all departments.

Research varies, but what we do know is that you cannot “buy” employees, at least not for the long haul. Money and benefits are often listed third or fourth, or even farther down, on a list of staff desires. When an organization is competitive in its wages, employees do not move based solely on a 25-cent raise. They may indicate wages as the reason for leaving, but all too often that’s not the case. It’s just that they do not want a hassle by explaining the real issues, or they are unaware of the importance of their input. True employee satisfaction is found in the intangible items they list in their satisfaction surveys. And what staff usually indicate they want in and from their work are respect, meaningful work, to know they are making a difference in the life of another, communication, good job preparation, and to know organizational expectations. They also want input into decisions that are made about their work and the organization, as well as teamwork and support—physically and emotionally.

Leadership is in a position to meet these needs and determine the facility’s level of staffing. It starts with the leader’s desire to create a work culture that meets the needs and desires of staff. Leaders have the power and authority to initiate programs and support others in their quest to create an exemplary workplace. It starts with the leader or designee’s vision and plan, which are then shared and enhanced by the leadership/management team and the entire employee base—all departments, all shifts. It is, in essence, a collective leadership model.


Visioning is the process of creating a dream organization without restraint of money or time. A well-developed vision includes laying out how things will work in all departments, and how it will feel and operate as a whole. The vision must be created and supported by all staff. If only the leader is involved in creating a vision, the vision belongs solely to the leader. It will not unite the entire organization.

Staff retention is enhanced by a reason for being, and vision is the motivator and driver. It is something to work for and toward. If there is no vision, employees simply come to work, do their own individual thing, and go home. There is nothing that binds them, unites them, or excites them. There is no direction, no destination, nothing to work toward. Without a vision, staff do not know what is expected, what they should do, or how they should perform. If the leader has no vision or destination in mind, how does staff follow a leader going nowhere?

Once it’s created, the vision should be used as the basis for all decision making. When faced with an issue, one must look to see if choices being considered are consistent with the organization’s vision. Decisions should be examined on the potential impact they may have on everyone—all staff, all departments, and all shifts. It should also be reviewed from the perspectives of the residents, families, and community.

Vision should, once established, be a topic of conversation that takes place with all members of the organization at least annually and anytime it appears that the group has lost its way. Heightening ongoing awareness keeps the organization together in heading toward the same positive direction.


Employees have consistently told researchers that a lack of respect severely impacts their organizational satisfaction. It is sad that respect is an issue that even has to be discussed, but it is one that continues to be paramount in long-term care. Respect must be a core value, and that means respect for all people at all times, regardless of who they are or what position they hold.

Leadership must establish respect as the foundation of how everyone will work together. This includes respect from staff to residents, staff to families, staff to staff, and the reverse. Demand it and do not waver. While it is not often necessary, it is important to remind residents and families of your respect policy. If they are unable to do so, asking a resident/family to leave may be appropriate given the fact that they are unhappy and may be more satisfied in another facility.

Cost is no excuse; time is no excuse. Respect does not cost anything except commitment to the concept and maintenance of it as a core value. The reality is that leadership can demand it: Respect others or leave.

Successful Staff Selection

When selecting staff, it is important to first find those who have an interest and willingness to support and work toward the vision of the organization. If this doesn’t exist, over time the individual will not be successful. Every organization is not the right fit for every person. Be clear about your direction and let potential candidates decide whether it is right for them.

In the selection process, the “person” is more important than his or her experience. The culture of long-term care is changing and it is critical to have employees on board with the changes you are trying to make. Years of experience are not helpful if the potential employee does not support the organization’s vision, standards, and expectations. Teaching a new employee a new task or process is easy, but teaching them to care is impossible.

However, do examine work experience when selecting a new person for a job. If the candidate frequently moves from job to job, chances are he or she will not be with you very long. Time and energy are best spent on those who are committed.

When interviewing, it is important to show potential employees the entire facility, not just a plush office or a beautiful lobby. They should see the entire campus and understand all levels of care that they might experience in their job, so they are clear about what their job will entail and the residents who will be entrusted to their care. This alone can reduce the rapid turnover experienced by staff who are unaware of the reality of the job.

Have potential employees wait for the interview in an area where others can see them—a receptionist or staff person. These observers will note many behaviors that predict future behavior. For example, organizational monitors have witnessed applicants who have fallen asleep, who seem afraid, or who ignore residents and other staff in their proximity. Other prospective candidates have spent the entire time talking on their cell phones or leaving frequently to go outside to smoke. Observation of behavior is valuable when hiring for a sense of commitment to a consistent and desired culture.

Staff Orientation

Why is it that many seem to assume that once a person is hired in long-term care, he or she knows exactly what to do? New employees do not know. First, they do not know the residents, where supplies are located, the people with whom they are working, or whether they are expected to work together as a team. New employees do not know the processes that have been set up to accomplish tasks. In general, newly hired employees will not know what you expect them to do and how to act if you do not tell and show them.

That is why orientation should be mandatory regardless of the new employee’s related experience. A reasonable departmental orientation period is two weeks with a combination of lecture, discussions, mentoring, and working with a colleague. In addition to the two weeks, it is helpful to hold an orientation simply to introduce new staff to all departments and their roles. All orientations should consist not only of duties and tasks, but how they are to be accomplished and the way in which staff should work with others.

Ongoing Education and Support

Staff will not learn all they need to know in orientation. Learning and teaching must continue throughout their tenure. There are always new residents, new diagnoses, new situations, and new information available, all of which present opportunities for learning. Sharing information that is new or new data about a specific resident serves to enhance care by making all staff more knowledgeable. The more that the employees know, the better they perform.

It is also an opportunity to learn from one another. Ongoing, routine sessions offer a wonderful opportunity for everyone to problem-solve about residents, processes, or procedures. Listening, sharing, and learning from one another is rewarding for all who participate. It cements staff relationships, encourages teamwork, and helps everyone to keep in touch with each other’s needs.

Providing such educational programs does not have to be a major expense. Each week programs are held at least twice on each shift. Each educational program or forum lasts for one half-hour and is repeated to allow all staff the opportunity to attend. Programs are an effective means of educating staff and staying involved. Each weekly session can be assigned to a member of the management team who is responsible for the program, whether he or she conducts the program or arranges for another to do so. Managers and administration taking turns provides an ongoing program for which the burden is not on one person and offers a mechanism for relationship-building in all departments.

Staff education provides a more stimulating and motivating environment in which to work, and it demonstrates that all staff are valued as students and, in some cases, as teachers. It provides an opportunity to stay in touch with the needs of staff, because forums serve as an ongoing source for communication. In addition to all of the other benefits of ongoing programs, they are fun: fun for staff to get together, to talk, to laugh, and to learn together.

Staff Participation and Ownership

Employees want to know what is planned and why something is being done in a particular fashion. They want to have a voice in the decisions and feel part of an organization. They want to know what and why. Often, giving staff the “why” leads to better decision making in the future.

All too often, we talk about empowering employees, but rarely about preparing and educating them to be empowered. An empowered employee can be a tremendous asset—an extension of leadership—but an uneducated yet empowered employee can be a nightmare. Once departmental staff learn the vision, mission, standards, and expectations of the organization, it is appropriate to genuinely empower staff by allowing them to make decisions about their work.

Educated and empowered employees can be decisive. They know the overall vision and expectations of the organization. They can act confidently in providing the best care, no longer requiring approval to act in every situation. Being allowed the opportunity to act responsibly brings about random acts of kindness from staff.

Recognizing and Celebrating Accomplishments

Recognize all accomplishments in the workplace, no matter how small, and do so individually at the time they occur. Whether for a skill demonstrated, a good job done, or extra effort or assistance provided to others, everyone needs to know they are valued.

A wonderful mechanism for recognizing staff is to seize every opportunity to nominate employees for local, state, or national awards for their positions. Often hospitals, state organizations, and national organizations seek nominations for exceptional performance in long-term care. Submit qualified employees for these awards. There is nothing more rewarding than to see a colleague receive such an award.

Parties, spontaneous and planned, as well as celebrations, serve to enhance the mood and atmosphere in the facility. Special days can be planned: sporting days, holidays, and sometimes “no reason” days. Who said you can’t have fun at work? If you don’t, perhaps you are working in the wrong place.

The Only Story

Research indicates that satisfied staffs lead to satisfied residents and families, which in turn increase census and improve financial outcomes. The perpetual cycle of staff turnover will continue unless leadership takes the initiative to implement organizational programs that prepare, educate, include, and nurture staff. This is not just a feel-good story. It will soon be the only story for attaining success.

Susan Gilster, PhD, NHA, Fellow, is a leader in innovative healthcare project development. As an educator, researcher, practitioner, and consultant, Dr. Gilster has published and presented nationally and internationally focusing on leadership, organizational development, staff retention, and Alzheimer’s disease and dementia care and programs. Dr. Gilster developed the Alois Alzheimer Center, which opened in 1987 as the first freestanding dementia facility in the United States. Dr. Gilster has published her innovative models and systems in two books: Changing Culture, Changing Care: SERVICE First and A Way of Life: Developing an Exemplary Alzheimer’s Disease and Dementia Program. For more information, phone (513) 673-1239 or visit or As an educator, researcher, and writer, Jennifer L. Dalessandro, BS, NHA, has been an innovator in long-term care for more than 18 years. She is the Assistant Administrator and Research Coordinator of the Alois Alzheimer Center. She has helped the Alois Center to evolve into a person-centered facility that continues to be service-driven. The facility has earned numerous deficiency-free surveys and the ACHA/NCAL quality improvement award. In 2006, the facility was one of the top 25 in Ohio for family satisfaction.

To send your comments to the authors and editors, please e-mail gilster0208@nursinghomes

Topics: Articles , Facility management , Staffing