Staffing Comes to the Blogosphere

Editor’s Note: Readers with access to the Internet and, more specifically, to our Web site,, may have noticed a rather interesting outbreak of conversation over the latter part of May in a “blog” initiated by Paul Willging. Yes, that Paul Willging—one of long-term care’s most prominent leaders, spokespeople, and analysts for the past 25 years, a professor at Johns Hopkins University, and the author of numerous highly provocative commentaries for this magazine over the past several years. Paul almost always generates response, and he didn’t disappoint this time, either—even though this was his first venture into the exotic “world of online.” Paul started with a simple comment and question about long-term care staffing and, within days, had sparked an outpouring of eloquent and telling observations from readers throughout the field. The so-called “blogosphere” allows anonymous contributions, which perhaps in this context was a good thing—the comments were pointed and personal. Read them and see what you think, perhaps even add your own two cents, if you’d like, at the Web site. And, oh yes, welcome to the new world of long-term care communication.

Posted on: Tuesday, May 13, 2008 11:26:35 AM by Paul Willging

Recently the Institute of Medicine produced a prepublication copy of its long-awaited report on the healthcare workforce. It confirmed what we already know: “We’ve got trouble right here in River City.” Nurse aide turnover, for example, is running at 72% per year (and other studies have it closer to 85 and even 100%).

Some might argue—so what else is new? With the pressures of the job and with reimbursement essentially capped by Medicaid at only slightly over minimum wage, what else can one expect? Others might say: That’s nothing but a lame excuse. We know that, with the right atmosphere and management style in a nursing facility, average turnover can be cut at least in half.

I really want to know what those of you on the front lines think. Is the issue one of management? Or reimbursement? Or a combination of the two? Let’s talk (or argue?) about it.

Wednesday, May 14, 2008 1:17:06 PM by Laura

We have 40% turnover with our CNAs calculated from 10/07 through 4/08. This is down from 75% 18 months ago. We are moving deep into culture change and are educating, using Eden as well as LEAP in the nursing areas.

Wednesday, May 14, 2008 3:42:13 PM by Anonymous

I have worked in long-term care (same facility) as an LPN for 28 years. I have seen CNA turnover increase greatly since I first started in 1980. Pay is a factor, but I truly believe that education is one of the areas that is the most different now than then. We had a higher retention rate when the pay was $3.50 per hour than we do now at $8.00 or more per hour. Back when I first started, even though the CNAs weren’t licensed, they were trained for weeks and weeks, one-to-one, until they were comfortable enough to be given an assignment on their own, or they took a class in their senior year of high school (or enrolled as adults in the class) that lasted an entire school year. Those CNAs stayed much longer on the job than the ones we have now. We were fortunate to have one wonderful lady who worked for 50+ years as a CNA before she finally retired, and all our long-term CNAs come from that time period when they received more training before they were “turned loose.” Nowadays, the CNA classes last 2 weeks, they have classroom time in the morning and floor time in the afternoon, and when the class is over they are put to work on “orientation” with an experienced CNA, but expected to complete their own workload. The experienced CNA also has her own assignment and often does not have or take the time to “train” the new CNA. The “new” CNAs sometimes don’t really have any idea of what is required to take care of this population after this short a training period and are expected to complete full assignments much too soon, which is probably the reason we don’t have anyone left out of the classes in six months time. We also have quite a few displaced workers from factory shutdowns and layoffs who come into this field without a real expectation of what all is involved in caring for sometimes very sick and often very cantankerous but loveable older folks. We are thankful for the good CNAs we have and for the ones we can get to stay who, with time, become very good CNAs. I believe that if more time were spent on education it would result in people who, first, know what they are getting into as a CNA, second, people who are thoroughly trained in all aspects of the job performance and, third, people who aren’t well suited for or do not like to do this kind of work leaving it before they got to the actual job. The CNAs are the backbone of the facilities—we would not be able to provide care to the residents or operate the facilities without them, so why would we not give our “backbones” all the strength (education) we could to make them stronger?

Thursday, May 15, 2008 7:46:13 AM by Kim

As the above commenter mentioned, the training is not good enough. It’s common nowadays to see these CNA mills push students through in a week or two. Little to no actual preparation for the real day-to-day work is provided. Yes, the skills are taught, but barely so.

Supervision is an issue. Our charge nurses are overworked and we’re left to fend for ourselves. This is OK for some things but not everything. Nothing is more demoralizing than watching your peers deliver poor, inadequate care, and when you speak up about it nothing is done. Names on the schedule hold more value than the care given by the names.

CNAs are expected to do too much in too little time. Unreasonable patient loads (ratios) cause many of us to believe we are failing at our jobs. And management certainly tells us we’re failures when we’re too “slow” and don’t get it all done in a timely manner.

CNAs work hard. We lift, roll, turn, reposition, transfer, push, pull, and otherwise move residents many, many times each shift we work. We also get hit, kicked, punched, our hair is pulled out, and we’re put in harm’s way often. Our bodies take a lot of abuse to do this work.

CNAs are paid pretty crappy wages to put up with all this. So, we leave the work to go to McDonald’s or Wal-Mart, where we make more money per hour and often get better benefit packages. And more respect from our bosses.

Solutions? Culture change is a big one. Turning the management hierarchy upside down is another. Also, better screening of new hires, mentoring programs for new aides, career ladders, and involving the aides in operational aspects of the facility. Not to mention better pay and benefits and, of course, lower ratios. In other words, the work we do should be respected. And valued. Money needs to go to action and not lip service.

Nationally, I think the standards for CNA training should be much higher. Each state has its own required number of hours for the initial training, yet we’re seeing more and more aides who are not prepared for the work.

Reliance on foreign workers is increasing, which in itself diminishes the work. Foreign people can clean bathrooms and hotel rooms, pick lettuce or work as a nursing home aide…think about that for a few minutes. It shows where the CNA stands in the pecking order.

More skills and actual work preparation is needed. The elderly need to be respected more as well—until that happens things aren’t going to change much. People live their lives and worry about the economy, their kids’ college education, politics, American Idol…there is no focus on old age and the needs of old people. No one cares. Except the overburdened and overworked CNAs.

Thursday, May 15, 2008 11:57:52 AM by Anonymous

The problem is exclusively the lack of real management. The average DON doesn’t have a BSN [Bachelor of Science in Nursing], so that means that more than likely they have never taken a management course. AIT [Administrator-in-Training] programs for administrators are woefully inadequate. In most states, the required text is James E. Allen’s Nursing Home Administration, which is a poor excuse for a college textbook. In fact, I believe it was the second edition of the book that literally stated that in a dispute between a CNA and a nurse, the administrator must always take the nurse’s side because there was no way a CNA could be right.

CNA classes are too short, as Kim has pointed out, and stress the theoretical rather than the practical. Full-time class instruction should be limited to three or four days, and then the aides should work on the floor during peak times (AM care, showers, 1st dry round, b’fast, and lunch) in conjunction with their mentor, and then go back to the classroom in the afternoon. Ideally, I would have this class time to focus on residents, where one would learn their life story, their psychosocial and medical status, and applications of this person’s particular status. For instance, Helen is on a secure dementia unit. The class would spend about an hour or so in the afternoon hearing about Helen’s life story, and then Alzheimer’s disease would be explained using Helen as an example. Her behavior problems could also be discussed in a similar fashion. This sort of thing would go on for at least a couple of weeks. By keeping people in class for longer, by slowly exposing them to the floor, and by combining this with peer mentoring, your turnover rate will plummet. Any idiot who complains about the cost should be reminded that it costs somewhere in the neighborhood of $4K to replace a CNA, and that most folks quit within the first 30 days.

Another serious problem is obnoxious supervisors. It has oftentimes been said that people quit their bosses, not their jobs. Anyone who holds any type of management position within a long-term care facility should be schooled on the art of coaching supervision. They also need sensitivity and basic communication training as well.

Thursday, May 15, 2008 9:56:07 PM by Holly

Nothing can make the staffing better than better respect for the profession. That’s the problem, too—we don’t get respect because we’re not considered professionals. The low pay and poor working conditions do equate to high turnover.

I think the leadership should be made to spend a year in the shoes of a CNA. At their pay. Every job I have held as a CNA that I’ve left has been because of nasty bosses, and not pay or hours or all the other abuses.

Saturday, May 17, 2008 3:44:41 AM by Anonymous

I worked as a direct care worker for 10 years in the same facility and finally left this year. (I still pick up a few shifts here and there, but only when I feel like it.) The reason was the turnover. Management kept shoveling whomever they could get into the positions, and they were lacking in even the most basic skills (such as being able to cook, clean, read directions, or sometimes even speak intelligently to the consumers), which made it even harder on the seasoned staff, who had to train each one as they came in. Over the last three years, I witnessed the entire staff list change. We went from having a “core” group of staff who had worked for years at this place, to everyone working there being employed under one year. As my last coworker from the “old days” left to find a different job, I realized that I had been “spinning my wheels” at this place too long myself and decided to move on to a different field. In 10 years, I had only gone up three dollars in pay from when I began. It was a satisfying job, helping to make someone’s day just a bit easier, but it just wasn’t valued in the long run.

When I pick up the odd shift here and there, I am always begged to come back full time—by the consumers and the management. (The frontline management had turned over several times in the last four years as well.) It breaks my heart to see the site in such dire straits, and I have been working there less and less because it’s just too painful to watch it go down the toilet.

From my perspective, the real problem lies with the attitude among the Director-level management on up. They seem to delight in making decisions and mandating policy changes without thinking of the possible effect on the workers or consumers. It was useless to make use of the company’s “Grievance Policy” to point out problems with any of the decisions as they were, shall we say, “less than receptive” to any dissent from the lower ranks. It usually resulted in an employee being given written disciplinary statements or outright termination notices. These same directors then scratch their heads and wonder: “Why in the world are we losing so many staff?” or “How can we reduce the turnover?”


Pay the staff a decent rate. Listen to them and take their suggestions seriously. Give them a reasonable workload.

Otherwise, sit back and expect more of the same (or worse) in the years to come.

I now have a job that values the work I perform and I love going in each day. Wish I would have found it 10 years ago and not wasted all that time working in a field that just doesn’t “get it.”

Wednesday, May 21, 2008 2:50:59 PM by Anonymous

I work for a wonderful nursing home in New York. Our training is six weeks long and not only includes theory but clinical applications. We have low staff turnover, usually because the aides go back to school, which is paid for. Maybe you are all in the wrong profession. Try going back to school. Or, do your homework. If you are all so well educated in the schematics of a well-run nursing home, get all the info before you begin employment. Stop resting on your laurels.

Sunday, May 25, 2008 5:32:21 PM by Paul Willging

While accepting the issue of reimbursement, most comments emphasized management, including the inadequacy of training. And that, anonymous commentator number one, is where I come from as well. Kim, Holly, and Anonymous #3 (are we afraid of retribution if identified?) mentioned “crappy wages” (or equivalent terminology). But more attention was devoted to “culture change.” Anonymous #4 put it best: “Listen to staff and take their suggestions seriously.”

It’s called quality management. It’s driven by data, it’s customer-focused, and it relies on an empowered staff. And I have no doubt as to the validity of Laura’s contention that the end result in her community was a reduction in CNA turnover from 75% to 40%.

But the process is just too expensive, complain the naysayers. More expensive than 75% turnover? And while I agree with your comments, Anonymous #3 (except, perhaps, for your reference to “idiots”—I think they’re just misguided), the economist in me suggests that an assertion it costs $4K to replace a CNA probably does not include what are referred to as “opportunity costs,” i.e. the costs associated with reduced productivity while the new aide is being trained.

Wednesday, May 28, 2008 12:32:48 PM by Anonymous

While I certainly agree that not all bosses are wonderful, I need to point out that folks on the front lines don’t necessarily understand what goes on behind the scenes, or why. We don’t always want to change things, sometimes we have to. And we would love to be able to pay more, but when Worker’s Comp premiums double, gas bills triple, and reimbursement is barely enough (or not enough) to pay for the care the resident receives, what do you do? We would love to lower the staff to resident ratio, but we can’t afford it and still keep our doors open. Each side has pressures that the other side can’t fully understand.

Friday, June 06, 2008 2:37:23 AM by Anonymous

I agree with the previous poster when he/she explained that “folks on the front lines don’t necessarily understand what goes on behind the scenes.” Couldn’t be more in agreement. In the 10 years I spent working in that field, not once did any person in management even attempt to explain the “big picture” to those who work at the direct care level. Instead, the only contact we would have would be policy changes or memos posted, dictating changes with no explanation.

Perhaps this is one area where a “culture change” would be beneficial. I know I would have felt much more a part of the team if I was treated more like an adult and not some nameless, replaceable cog in the machine.

Want to improve the lives of consumers? Improve the working conditions of those that work for you. Simple answer. Treat the workers with respect, or at the very least, like adults.

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