Just who will take care of mom and dad?

In recent articles attempting to predict the future for nursing facilities and assisted living, I suggested that both these professional settings share a common challenge: personnel. Where, I asked, are competent caregivers going to come from? There is no question that absent qualified staff, it's nigh on impossible to provide acceptable levels of service. And absent acceptable levels of services, we are likely to see increasingly disgruntled customers—in both sectors of the continuum.

And what is the likely result of that? Well, if history is any guide, the inevitable result will be more and more regulation.

And why is that? Well, we've traditionally focused on the most facile answer: Government has a propensity to ignore cause and effect. Nursing homes have traditionally been inappropriately staffed, not because management chose to, but because management couldn't afford to appropriately staff them. Government, the primary funding source for nursing homes, has shown itself unwilling or incapable of addressing the root cause of the problem: resources. It attempts, rather, to control the effects by simply increasing its demands for improved quality and totally ignoring the nexus with resources.

And why is assisted living preordained to suffer the same fate? Assisted living has proclaimed itself for years as the low-cost alternative to nursing homes. But only by increasing salaries can assisted living recruit additional staff. Higher salaries mean higher costs. Higher costs mean higher monthly rents, and assisted living loses whatever competitive edge it might have held vis-à-vis nursing facilities.

Both articles I wrote on these issues inspired enough reaction by my readers to prompt the editor of this publication to suggest an entire article dealing solely with workforce issues. Initially, I was skeptical about this—as if I had the solutions to the critical issues of workforce recruitment (and retention)! But, as it turns out, there are potential solutions to both problems. And, it dawned on me, the two are inextricably intertwined.

If you recruit badly, you can't hire. But worse, you can't retain. In fact, as important as filling the vacant position might be, your ultimate goal in recruitment should be retention. That is where the ultimate payoff is going to come.

But let's not get ahead of ourselves. Let's begin with the basic recognition that workforce issues are, indeed, the most critical of all those facing long-term care managers. Ours is an industry of caregivers. I've stated more than once that buildings don't provide care, people do. And that presents a challenge that keeps more than one community or facility manager awake at night.

We start, of course, with multiple disadvantages. Let's face it: The work is not easy. The pay is not good. The profession's reputation (rightly or wrongly) leaves something to be desired. In short, this is not an auspicious start to the recruitment process.

Not a week goes by that some assisted living or nursing facility doesn't make the press for its alleged shortcomings in care. As for the difficulty of the work, it's both physically and psychologically wearing. Let's look at the role of nursing aides, for example, who constitute more than 60% of nursing home staff. In a study conducted by the University of Michigan, nursing aides indicated that lifting patients, insufficient personnel resources, injuries from violent patients, and the possibility of acquiring communicable diseases at work were among their major environmental stressors. Psychosocial stressors were a lack of appreciation, physical and verbal abuse from patients, time pressures, and insufficient staff. And as for physical challenges, the U.S. Department of Labor, in a press release accompanying its 2003 nursing home ergonomics guidelines, offered as the rationale for its focus on nursing homes the “physically demanding” nature of nursing home work.

And for this we pay barely a living wage—an average of $10.61 per hour in 2006. That comes out to $22,070 per year. Try living on that! More to the point, try recruiting for what is reputedly one of the most demanding jobs in healthcare, in a profession that serves as a favorite whipping boy for a voracious media, offering salaries at that level. No wonder one of our biggest competitors is the hospital sector. It is less notorious. It requires less demanding work. And wages average nearly 10% higher than received by their nursing home counterparts.

But it can be done. I'm not going to patronize those among my colleagues who successfully recruit, day in and day out, even within the context of the difficulties enumerated above. What I am going to do is suggest that you maintain a critical focus on retention as you successfully recruit. And here I am going to rely to some considerable extent on the experiences of those who have already labored long (and successfully) in the vineyard.

One of those is Dwayne Clark, founder and CEO of ÁegisLiving and author of one of the best practical texts in the field, Help Wanted: Recruiting, Hiring and Retaining Exceptional Staff. Clark makes it clear in the very introduction to his book how devastating turnover can be to your bottom line. The National Association for Priority Leadership, he points out, estimates the cost of losing an employee to be from 150% to 300% of annual compensation. That means losing 10 nursing aides a year, at an annual salary of $22,000 per aid, can cost your facility $330,000 to $660,000 each and every year. Ouch! No wonder recruitment's primary goal needs to be retention.

But just what does that really mean? Well, for one thing, it means you hire as much for attitude as for skills. And if you successfully hire for attitude, and that attitude fits a company's culture, it is that much more likely the new recruit will become a long-term employee. The level of employee satisfaction will be high, the community's quality will benefit, and the likelihood of those two phenomena positively interacting to stimulate higher retention will be the end result.

Clark quotes Paul Klaassen, founder and CEO of Sunrise Senior Living, to that effect: “When we look at people, we have to look at their basic belief system. I am somewhat skeptical about people's ability to just change their belief system. We make sure we are hiring for our culture and a set of beliefs first. We can train the technical aspect of the job; you can't do the reverse.”

Clark also provides a tool well suited to eliciting information about “cultural fit” when recruiting prospective employees: the group interview. Certainly not invented by Clark, the group interview has been around for some time. It does, however, go counter to the more traditional approach to hiring. We all know the routine: the help wanted ad, the phone call or letter from the candidate, the initial interview, reference checks, etc., etc., etc. All this remains appropriate if what we're looking for is skills, basic personality traits, work history, and prior employment issues. It doesn't do much, however, in helping to determine if the recruit will “fit” into your company's culture (or whether you will fit into hers).

The best way to do that is to observe the candidate within a setting that places an emphasis on personal interaction with other candidates for the same position and with current associates from within the community. It can be extremely enlightening to observe the candidate who is not at all sure whether he or she is interacting with a potential competitor or even a future colleague. The response to questions, raised by anyone within the group, will reveal amazing insights about the individual candidate him- or herself. How respectful is she of others? Is he appropriately deferential to their views or does he attempt to dominate the conversation? What are her attitudes about prior employers? What is he looking for in future colleagues?

The group interview doesn't supplant the other critical steps in the hiring process, but it does add a flavor that is essential if the goal is to hire for cultural fit. Remember, our focus in recruitment is as much retention as it is filling the existing position. And retention demands an adherence to—actually an enthusiasm for—the culture of the community. If what you're looking for are automatons whose primary skill is the application of certain caregiving techniques within an unchanging, policy-driven environment, where success is measured by the absence of failure, then the traditional recruiting process might work for you.

But if you want innovators whose primary goal is to enhance the quality of residents' lives, and whose success is measured through their level of satisfaction, then the group interview might just be your cup of tea.

Now, let's say you've filled the position. Better, let's say you've filled it with someone who fits your customer-driven, staff-empowered culture; with someone who is constantly testing the levels of customer satisfaction though data and experience. How do you keep the employee on the farm? After all, isn't this what we're all about—recruiting for retention? You hired for cultural fit. Now it's your job to make sure that the culture is what you presume it to be. If it is, if your staff are satisfied that they, in turn, have chosen wisely, that you fit their culture, then you're halfway home.

Which is another way of saying that staff satisfaction is the key. The data are becoming more and more persuasive that a staff convinced of its empowered role within a common culture will not only reduce turnover, but (no surprise here!) will actually improve care. This is becoming increasingly apparent in both the academic and the trade literature. A recent article in The Gerontologist, for example, pointed to the positive effects of culture change, including the critical aspect of empowered staff, on turnover (not to mention resident care).

On the latter point, it is interesting to note the increasing consensus that relationships exist among staff satisfaction, customer satisfaction, and care outcomes. Some of the most exciting work in the field is being done by My InnerView, a company whose mission is to promote an evidence-based approach to quality in long-term care. In an article written for Provider magazine, Leslie A. Grant, PhD, shows quite clearly that staff satisfaction, reflected in turnover and stability, will predict a broad range of other performance parameters, including family and resident satisfaction, improved clinical outcomes (e.g., reduced falls and use of antipsychotic medications), and even occupancy rates.

Much of these data stem from lessons learned in the 2003 Georgia Quality Initiative, in which My InnerView collected data, created feedback reports, and provided training to introduce the principles of evidence-based, data-driven management to providers across the state. The relationships among job satisfaction, family satisfaction, and improved outcomes were obvious. Improved quality was evidenced by the reduced numbers of falls, decreases in the incidence of pressure sores, and fewer catheters used. As for employee stability, the research showed less nurse turnover, as well as lower levels of CNA and nurse absenteeism. And, finally, occupancies improved.

So, there you have it. Employee satisfaction is an eerily accurate predictor of excellence within the long-term care community. But maintaining high levels of employee satisfaction is, in turn, a direct function of a community's culture—a culture that is customer-focused, evidence- and data-driven, and staff empowered.

Nothing too new here. I've been writing and teaching about “culture change” before it even had a name. What has not been sufficiently emphasized, however, is an as yet unanswered question, namely, can you train people for this new culture in long-term care communities? Or is it an innate “talent”? Marcus Buckingham and Curt Coffman (First, Break All the Rules: What the World's Greatest Managers Do Differently) describe these certain personality traits—talents that can't be taught but must be sought as part of the hiring process itself. In short, you can train for skills—but you can only hire for attitude.

I'm coming to believe they're right. I'm also coming to believe that we in the profession have taken on too much of the “victim” mentality: “We can't hire and retain good people simply because of the financial environment in which we're forced to operate.” Let's face it, reimbursement can't be ignored. But, interestingly, that simply makes our job more of a challenge, not a hopeless exercise. Yes, we've learned from research done by My InnerView and others that wages are, indeed, a factor in job satisfaction. But they are not the most critical factor. In its 2006 National Survey of Nursing Home Workforce Satisfaction, My InnerView conducted a correlational analysis to identify factors that make the biggest difference when it comes to staff recommendations of the nursing facility as a place to work. (How employees recommend the facility to others as a place to work is generally considered the best single indicator of employee satisfaction.) Guess what—of the 18 factors isolated, pay ranked dead last. Number one? Management that cares!

There's not much you can do about pay. But you can make a difference as managers in the 17 factors that precede it—appreciation, information, orientation, education, and teamwork, among them. Are any of these outside your control?

So why don't we focus on what we can accomplish and not fixate on what we can't. We might be highly surprised and (for once) even pleased with the results.

To send your comments to Dr. Willging and the editors, e-mail willging1007@nursinghomesmagazine.com.


Paul R. Willging, PhD, was involved in long-term care policy development at the highest levels for more than 20 years. Dr. Willging served for 16 years as president/CEO of the American Health Care Association, was President/CEO of the Assisted Living Federation of America, and later went on to cofound the successful Johns Hopkins Seniors Housing and Care postgraduate program (cosponsored by the National Investment Center for the Seniors Housing & Care Industry). He is currently Associate Director of both the Johns Hopkins Medical School's Division of Geriatric Medicine and Gerontology as well as the Johns Hopkins Center on Aging and Health. He has enjoyed an equally long-lived reputation for offering outspoken, often provocative views on long-term care.

Topics: Articles , Staffing