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Retaining Staff in Long Term Care

Retaining Staff in Long Term Care June 3, 2022

Marketing, research and business development consultant in healthcare, human services and senior living.

Date: 2nd June 2022
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Retention in Long Term Care Webinar Resources

Facing labor shortages and cost hikes, many long-term care facilities are shuttering
Advocates say things will worsen when federal assistance expires in July. ABC News, May 3 2022.
Eli Cahan and Laura Romero. See:

For those of you who a copy are not marketers, and are unclear about “differentiation”, see Purple Cow by Seth Godin. See:

Why Healthcare Workers Quit. J Walter Thompson. 2003. See:

FACT SHEET: Protecting Seniors and People with Disabilities by Improving Safety and Quality of Care in the Nation’s Nursing Homes. The White House. February 28, 2022, See:

National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press.

DeNisi, A. S., & Murphy, K. R. (2017). Performance appraisal and performance management: 100 years of progress? Journal of Applied Psychology, 102(3), 421–433.

Society of Human Resource Management (SHRM). See:

Yager, E. (1981). A critique of performance appraisal systems. Personnel Journal, 60(2), 129–133.

Varney, S., Nursing Homes Bleed Staff as Amazon Lures Low-Wage Workers With Prime Packages. December 23, 2021. Kaiser Health News. See:

Transcript – Retention in Long Term Care

The pandemic is, yet again, looming. And while the pandemic had a role to play in the current staffing crisis, the seeds for this crisis were planted quite a long time ago, have been brewing, cooking, stirring, being cultivated and are now fully ripening.

The agenda for today is to talk about where we are in our current situation. Second, and I’d like to spend most time talking about this. What can we do now to retain in long-term care, recruit, and cultivate a robust human resources team in our long term care operations?

I’m going to focus on the retention in long-term care, recruitment, and cultivation aspects, focus on systems, going to look as, as clearly as possible, at systems that enable retention in long-term care, recruitment, and culture. Culture, cultivating good environments in which to work, going to talk about leadership and the difficulty and yet the importance of change and throw out at all. I hope to be focusing on practical steps that we can take to enable these systems changes.

So where are we?

Well before the pandemic, the median annual turnover for registered nurses was 102%. That’s in long term care. The turnover for licensed practical nurses, 80% and for nursing assistance, 98%. So what do we think of that? Do we just think that’s the price of doing business?

I’ve heard CEOs say that to me. However, in the current environment, the previous attitude toward frontline, direct caregivers, as well as entry level employees, such as dietary, scheduling. We can no longer consider these as interchangeable as disposable and perennially renewable resources, because they’re not.

We’ve just had two major releases within the United States, a fact sheet by the White House on Long Term Care, which was referenced by President Biden in his State of the Union address. And as far as I know, in my years in health care, 40 plus years in long term care, I’ve never heard long term care mentioned in a State of the Union address.

So it’s certainly a first, the White House fact sheet, and the National Academy of Sciences report, focused on staffing a lot. And in the White House report, there were 21 recommendations, which I’ve dissected and I put a blog on the website for you all to take a look at.

A big bunch of these recommendations had to do with staffing, inspections, and fines, including recommendations about reducing costs. So I don’t consider such a combination of improbable, incongruities to be practical. I’m going to, instead, try to focus on practical things that we can implement in our operational environments.

We got here through system neglect, and actually, there is no system for long term care. An articulate paper appeared within the past year, in the New England Journal of Medicine, making this case pretty powerfully that there is no system. In long term care, it’s a cobbled together rag tag, disjointed set of regulations and provisions. Ageism is an important part of it and I’m going to drill down a little bit into that further.

Nobody looks forward to going into or relocating into a nursing home. People don’t even relish the idea of having homecare at home. The question arises as to whether or not long term care is a business or an enterprise.

The current regulatory environment seems to view it as both a Social Safety net service and as a business. And I think that in part suggests why we got into this mess and then you add the pandemic, the pandemic was precipitating because of the staffing crisis but not a causal reason for the staffing crisis and we’ll drill down a little bit into that too.

Old adage, follow the money. If you look at what the United States spends money on in health care by category, we can see that this top line is the United States here, and over here, this medium blue is long term care, and it spends per capita $516 per capita per year.


In the United States 2018, comparable country average, that is to say, OECD countries and use the list, and here, provided by Kaiser Family Foundation, average in OECD countries is more than twice that.

So what does that say? It says that we’re not spending as much as comparable Western countries on long term care. Well, is that because we have a lower disease burden of chronic illness? Is that because we have more efficient systems and we don’t have to spend that much? Because we are just more effective at delivering long term care. The answer is no.

So the reasons for that come down to a few. Then you add the pandemic, and we can see here that the Nursing and Residential Care Facilities payrolls plummeted as a result. The pandemic plummeted as a result, the emptying out of many of these operations, the suspension of home, and community based services, as well as the fear among the workers themselves, illness among the workers themselves.

And before, you know, you’ve lost 400 plus thousand individuals’ from a workforce of about four point five million. So, that’s a pretty significant loss. And when you look at the winners and the losers since February 2022 and November 2021, nursing and residential care were among the biggest losers, in terms of overall jobs in the job market according to the labor department.

This is really significant, in, in, in several ways. And one of them is, well, where did these workers go? Some of them didn’t work for a time, but others stayed in the workforce, and where they went was they went to other health care provision settings. So community care, and nursing care facility workers went to outpatient centers, physician offices, home healthcare services, hospitals, and overall other types of health care settings, when they could.

Some long term care employers were hurt, and have been hurt more than others. Assisted living hasn’t been heard, for example, as badly as nursing care in the end, in the sweepstakes of job losses. And so the question comes, too. Many people ask, Well, what are we going to do? Is money the answer?

Do we simply have to pay more? Well, wages are going up. Earnings are up, but, as you can see here, there’s a profound gap, according to the labor Department data, Between all private service sector employees, and nursing, and residential care facilities. The gap is substantial, and you’ll see that it tracks along very nicely here. And it’s unclear that operators in the sector are going to be able to overcome this pay gap, the value of a CNA based on his or her salary. As we know, mostly her salary, the average in the country.

Is $$$ the answer? Earnings are up

According to the Bureau of Labor Statistics is slightly under $  an hour, now, that’s going up. But the fact of the matter is, that’s 17% of the CNAS in the United States live below the federal poverty line. 9% of the CNAS live below the federal poverty line, compared to  % of all American workers, so the question is, what is enough? What’s enough salary, what’s enough benefits, how do we value this position?

If we devalue the position based on money and pay, the rest seems pretty clear about what we think of, or what we had thought of these frontline workers. And the root cause analysis, I would submit to you that the lack of value devoted to these workers is ageism.

It’s ableism, it’s sexism, and it’s racism. And that’s just the way it is. A big part of this workforce are elderly, women, and elderly women of color and persons of color makeup, 59% of CNAS, and 26% of LPN’s working in long term care various long term care.

So these are cold, hard facts. So the question is, what do we do now?

These are factors which are outside of your operation and not necessarily under your control. You have no control. For example, over what Walgreen’s down the street chooses to offer their entry level employees.You have no control over what Amazon puts in its package for educational benefits for it or child care benefits for its workers at the warehouse or distribution center.

Right down the road, from you, you have no control over that. And you have no control over the overall hydraulics in the labor markets. The labor markets continue to be extremely tight with there being lots of jobs and not enough age qualified individuals to follow up on those jobs.

What is within our control is to listen.

I’m going to be very specific about what that means. Where to listen, learn and to change. That is in our wheelhouse, our best case response and long term care to retain employees, That’s the first step.

It’s not to recruit more, It’s to retain, keep what you’ve got. And to get better at it, get better at keeping the team that you have, The individuals you have, who represent the service categories, represent the psychological profile, the demographic profile, that represent those whom you wish to keep, get better at keeping them. And I’ve got some very specific suggestions about that, with regards to recruitment. We need to earn a greater share of the supply that’s available of what you need.

Earn a greater share of the supply of what you need. You can’t, you may not be able to compete. I’m going to say you can’t compete with what Amazon or Walgreens does in your marketplace area. But you can compete in other ways that would render your employment at your location more attractive, more compelling for a certain important segment of the workforce available in your marketplace area. And finally, cultivate There’s been an awful lot of ink spilled over long term care, culture.

Culture. I’m going to define it further, but culture produces relationships, and it is the relationships between and among individuals’ employees, supervisors within your work environment, that dictate whether those individuals are willing to stay, or whether they’re willing to leave. And I’ve got some anecdotes and very specific examples about what I mean by relationships. So first, the first thing that we have control over is keeping what you’ve got. So the first step of keeping what you’ve got is understanding why people leave.

And it’s very easy, it’s a very quick fix for us to fall back upon, well, they got a better job, there’s almost always more to it than just that. So it’s important for us to understand why people leave in great detail, and as often as possible. And the best way to do that is to ask people. There are 15,000 nursing homes in the United States. There are tens of thousands of assisted living residences and even more home health agencies.

And my hunch is that fewer than 10% of that entire array of employment environments conduct effective, rigorous, exit interviews on their employees. And why not? I think it’s because we just haven’t had to do it. We’ve looked at the population that input that we employ as replaceable as a perennially renewable resource. They are not.

And yet other sectors, other service based sectors, do these exit interviews much more rigorously, much more effectively, and harvest the benefits associated with doing them. So we want to ask why they’re leading. We’ve also, we also want to ask, and we can ask this on exit interviews, but we should also be asking this on a regular basis, why individuals have stayed? It might be your location, It might be momentum, I’ll have just stayed because it’s been here so long, I wouldn’t know what else to do. It could be your physical location. You could have the job flexibility, the hours of work, allow the staff person to fit in exactly another job and childcare in their busy lives.

We need to understand what those factors are in order to understand what we can do in order to be even more of the good things, and less than the bad things, about why people want to work for us. So if we’re losing 20% of our workforce, which is what the numbers look like across the country, it may be worse, or it may be better in your particular location if we’re losing that much of our workforce.

It behooves us, take a systematic systems based approach, and better understand why they’re leaving and why they’re staying. Because that’s something we can do, we have control over that, and we can gain insights from it. And here’s what we’ve heard, what we hear when we do our surveys, and interviews, interviews with departing and current employees The number one reason people leave, people say she just didn’t listen. I can’t tell you how many times we’ve heard that in the tens of thousands of surveys that we’ve done. This is one of the most frequent phrases that we hear.

She, he, can fill in the blank, the executive director, the leadership, the supervisor, fill in the subject? It’s almost as many individuals as you can imagine. What does that mean?

It means that the individual, the supervisor, or the person from this respondent identifies just didn’t take the time to listen to that individual. If we’re going to get serious about competing for the dwindling category of resource, which is prime working age individuals, who are willing and interested in being employed in long term care.

The second reason is money and compensation, And this is a new development. I have to think of my family. We’ve interviewed individuals who haven’t wanted to leave employment in long term care, who are committed, and even in some cases, devoted to the patients and the individuals they serve. But when Amazon offers a pay rate rise of 7$ an hour, plus educational benefits, plus a more flexible work schedule, the individuals say uncle, they say, I have to think of my family.

And then the third category, which is, again, a recent category, is burnout and fear. And that shows, like, concerns about an individual who’s elderly and living with us. On the frontline care worker in a nursing home take care of outside the home, an aunt and uncle, a stepmother and stepfather.

And they’re concerned about that. Then the burnout shows up, as I just can’t do this anymore. And we’ve all read a lot about that. In fact, my sense is that we will discover, in very short order, that the quote, unquote, burnout that’s being read about really has all the hallmarks of post-traumatic stress disorder.

So what can we do?

RETAIN – What can we do?

Let’s look at systems faced, interventions that we can undertake that will improve retention in long-term care

First is performance appraisal. So, what is performance appraisal? Everyone who’s employed knows what a Performance appraisal system looks like, and the issue with performance appraisals that we can do is to increase the frequency of performance appraisal and reduce the complexity.

In most institutions, and most organizations, the performance appraisal system looks like once annual, or twice annual at the most. Sit down interview between a boss and the subordinate. Where the Individually being evaluated is reviewed by the boss against some standards or behavioral criteria against some job objectives. These meetings, especially during a pandemic, tend to be relegated to secondary.

They tend to neglect it. So, we’ve gone now, two plus years.And my hunch is that an awful lot of you out there haven’t been adhering to your regular performance appraisal schedule. I would submit to you that once a year performance appraisal is more deleterious and beneficial.

Performance appraisals need to occur on a regular basis. They need to occur in a way that gives both constructive and positive feedback to the employee and solid feedback to the employer, to the supervisor, needs to be two-way, needs to be very frequent. It has to be structured in a way that there’s no big emotional charge built up around it, which is what happens now. Oh, my performance appraisals are coming up. Oh, what are you going to do? What you gotta do, it’s just, so counterproductive.

There’s been some interesting research in this regard, which is not quite definitive, but it’s certainly directional suggesting that the typical in your performance appraisal sit down interview is counter-productive and not very constructive. There’s some simple models for doing this. I will include some links to the Society of Human Resources Management and how these can be done much more efficiently and much more effectively and if you want, you can always be in touch with me. I’ll explain or give you some suggestions about that, increase frequency, reduce complexity.

Exit interviews. Is this person a possible rehire if the person that you have left or that you have terminated is a distant dot in your rear view mirror? That’s too bad because there, there’s some people who have left who would be terrific re-hires for you.

They may have left, because Sally didn’t get along with George, and they were fed up with it so they moved on down the road. Well, if Sally or Giorgia are no longer there, it may be time for Mary to come back. So, former employees of your operation can and should be considered very interesting and potential good resources for rehire.

That’s just one value or possibility behind exit interviews. Current staff, surveys, and interviews. Now, many of you are conducting employee interviews if you’re not conducting employee surveys. Employee interviews. I don’t know what to say, you really.

It’s an important oversight, and it needs to get fixed, because the critical piece we’re going to see just a little bit here is that your single best recruitment channel are your current employees. Your single best recruitment resource should be your current employees. So undercurrents staff surveys and interviews here. I’ve got a willingness to recommend or refer, then, actual referrals.

Because if, if your employees are referring potential employees to you, then that’s saying everything that needs to be said about that. Individuals’ loyalty to you, their satisfaction in working with you, and their engagement in your mission, purpose, and your, the work that you’re doing.So, it’s a tremendously important insight into the culture, into the attitudes, perceptions of your employees. And then the other thing that we can do is take training communications much more specifically and seriously.

And in the two skills categories that I’d like to emphasize today and have you take away, The first is listening. Empathetic listening programs are everywhere on the internet.

They’re available on YouTube. There are structured, empathetic listening skills, workshops available. There’s printed material from the Society of Human Resources Management. In other words, the only reason for not doing this is that we haven’t paid attention to it and actually started to do it.

And I’m encouraging, even urging you because listening is absolutely at the heart of building relationships. We know this from our personal lives, and the same is true in our employed environments. If we don’t listen, we’re conveying the message that people don’t care.

The second piece here is conflict. It’s just not possible to have an intact work group without conflict.

It’s just not possible in these environments with its workforce being constrained by regulatory pressure, even fine’s being seen, lowered utilization rates, therefore, revenue pressures. In these highly pressurized environments, conflict is inevitable, and yet, how many of you have been trained in managing conflict effectively?

So there are very good, skills based training programs available to teach how to identify your own conflict style, how to identify other people’s conflict styles, and to work through the conflict without working on the person without working on me without reverting to personal, snipes, jibes or just ignoring people altogether.

So empathetic listening, conflict management, two, extraordinarily important training, interventions for every long term care operation.

And for retention in long-term care, when we do our staff surveys, standard sorts of questions look something like this. When others asked me about my job, I urged them to consider, tell them to possibly consider, or urge them to never consider. And if you do this, if you set this survey up correctly, employees will answer this question for you, and indicate to you whether or not they are willing to refer other potential employees or even former employees to your operation. The best case response in the retention in long-term care category Is to keep what you’ve got and to get better at keeping what you’ve got for recruitment is to get more of the supply.

What you need, and under culture, is to develop stronger relationships, and all of the suggestions so far will enable us to do that. So, in terms of recruitment, it’s important to look at who would want to work for you. That’s not a snarky sort of statement. That’s an actual systems based strategic question: who would want to work for you?

And the question then becomes thinking inside and outside of the boxes. This is data that you see on the slide here from Kaiser Family Foundation on the long-term care workforce and who they are.

So the gender, social economic, even the location area, where individuals live, their zip codes, it’s extremely important, and would help you to analyze, but from whom you will attract further employees, additional employees, new employees.

And when we’re looking at systems based recruiting, we look at where the supply is, where the supply of H, qualified individuals are. Generating leads, lead management, speed to offer, and on boarding. So, what we’ve found is that there’s a significant drop off, even in our clients that are successful at generating what should be enough leads or inquiries for opening open jobs.

That there’s very often a delay of many days, sometimes, weeks, in moving that candidate through the system. In order to get him or her to a point where they’re being offered a job.

That time allows a drop off in that individual’s interests, or it allows that individual to get recruited by another company. And that is just painful. Because you’ve paid for that lead. You have earned that leads through your recruitment activities.

This is something that’s of value to you and it’s being lost because of this lead management system. Your ability to offer that, get that person to the job offer quickly. So I would urge us all to do a crappy to do a quality assessment. On our intake hour lead generates our lead processing systems.

Who has to approve what forms need to be filled out? Are the forms online and accessible online so that the individual can fill them out herself or himself? All of these things are systems based obstacles to your conversion, a higher percentage of these leads. The final piece about onboarding the way we’ve got lots of research, stackpole and associates has done tens of thousands of employee surveys in the long term care sector and employee surveys of employed individuals shortly after employment.

And it’s very clear that within 30 to 60 days, there’s a profound drop off in individuals’ willingness to stay in employment with their new employer, so the 30 to 60 day period is an extremely important, to that individual’s long term loyalty, and engagement with that job. So I would urge you to take the same systems based approach to looking at onboarding. Everything from, what does the employee handbook look like? How much are we trying to just reiterate stuff or say stuff that should be printed or handing out gobs of printed material to a 30+ something? Not gonna read it.

So, it needs to be streamlined and looked at, strategically, that’s a systems based obstacle to more effective recruiting and retention in long-term care. So, what’s the best source of leads for employees in long term care?


Your existing employees are absolutely your best source for leads, Your existing employees, if they are engaged, your existing employees, if they’re loyal. They have broad social networks of their own, And they are talking about their experiences at work, they are consuming your service as a service provider of employment. They are consuming that. And as consumers, they have distinct opinions and perceptions, which they are. They are freely sharing with their friends and families. So your existing employees are your best source of recruitment. Your worst source of leads for recruitment are cash incentives.


So, we’ve seen a proliferation of employment incentives in the form of cash, bonuses, hiring bonuses. This is absolutely a terrible idea. The data about this is so clear. People who accept cash bonus offers for employment. It’s in all service sector categories, all service sector jobs, they will jump at the chance of the cash bonus, and they will jump back out again just as quickly and as easily. Job hoppers hop, that’s what they do. So, if you really want to both burn cash, and be profoundly disappointed, because the position is empty again, in two weeks, go ahead and offer a cash incentive.

If you feel that you need to offer a cash incentive, or some type of incentive, as a competitive move in your local marketplace environment. Because other people are doing that and they seem to be attracting people, please don’t be seduced into that fawlty logic.

There are very good things that can and might be done in the form of incentives Other than cash incentives which would have more meaning and more retention capability than just the cash, OK so if employees are our best resource, are you currently? It’s a challenging question. Are you currently receiving referrals from your current employees? If you are not, why not? And if you’ve already got a referral program in place, here’s what you need to do.

First of all, you need to announce, you’re canceling it, you’re canceling, you’re employee, referral slash employee, referral bonus, whatever you call the thing. You’re canceling it because it’s not working. Then you’re going to recruit staff, not the usual suspects, but staff at the ground level. This is right out of W Edwards Deming Quality improvement. You’re going to recruit those individuals not based on the fact that their supervisors, or Maria is the boss’s favorite, none of that stuff. Not the usual suspects, and you’re going to give them a task within days.

Come up with non cash incentives or ideas that will help attract employees, current employees, former employees back or new employees to work within your operation and hold them to it.

Ask them, get them to volunteer if you can, appoint them if you need to. But explain the seriousness of the situation if you want their ideas. And then take their ideas and implement them publicly. Now they come up with ideas that are financially unfeasible or would clearly break off risks. A list of rules. You don’t leak legally, not feasible. You can explain that. Invariably, there are a few nuggets in each of these groups that can, and when implemented, have enormous benefit and for the first of which is to just show the staff, the rank and file, that this contribution was listened to and implemented in a serious fashion.

Now, if in your employee referrals program, you struggle implementing an employee referral program, you’ve already answered an important question, even if you don’t like the answer, In other words, if they’re not willing. If your employees are not willing to refer other people that they know to their family and friends to work at your, in your operation, the question is, what would we need to do? What would we need to do in order to create fans’ ambassadors or champions in the community?

You can ask them. Now, if you ask the right way, if you ask in an open, safe environment, if you ask several different ways not to intimidate, but to make it clear that you want the answer, you’ll get the answer. Somebody will say to you, well, you can get rid of George. She’s such a pain in the ***. Then you’d know what the issue is and you know what the obstacle is. Well, you could offer us all the other two bucks an hour, Well, if we can’t offer you two bucks an hour. What might we do?

Now, if that sends you to talk to the Medicaid board about increasing the rates at your center, many of you already have that conversation. The question is, are you sharing that information with your employees? Do they know how hard you are working to get them, what you believe they deserve? And my hunch is that many of your employees aren’t aware of how hard you’re working to do that.

Finally, with regards to recruitment, I want to talk a little bit about advertising because historically, advertising has been an important part of where we are, where long term care operations went to find new employees. And this is a, this is a pretty typical print advertisement for certified nursing assistants, I Just pulled this out of an online newspaper and eternal.

This is what it’s done. This is how it’s done now. Oh my gosh, please don’t, That’s just absolutely the wrong way to do it. If you want to attract individuals of a particular age or demographic profile, and you should know who that is, then you want to talk to them, where they are, and here’s a snippet from Tech Talk. I pulled this over a month ago now. This person, Michele, was talking about working in long term care. She loves her job. She’s a nursing student and works as a CNA.


The tick tock clip is absolutely adorable. And she looks like what you’re after, and so you’re apt to attract more of her. If your target is an older Haitian population in your marketplace area, there’s a dense population of patients, then you know where your app is to see them.You’re your app to see them, your app, to reach them through public posters, to billboards and bus stations of the transport centers. So you want to go where they are, but your first step is to understand what you’re after. These little postage stamp ads in newspapers and on job boards. Just don’t cut it anymore.

Here’s another ad that I thought was quite good, because it gets to the issue of the altruistic appeal of the nature of the work. Love your job and your team members, too. And this demographic. She has to like whom she works with.

So, the dynamics have changed a lot. And if we’re going to succeed, we need to adapt and adapt effectively. So, the best case response here is to retain recruits, and now I want to talk a little bit about cultivating culture and relationships. I want to get clear about what I mean by culture.

So these are the unspoken rules that dictate behavior within groups, and I think we can all identify with that definition. Culture is too often, the root cause of our failures, and not often enough a root cause of our success. There are some stellar examples of organizations in the long term care sector, without standing cultures. I just love this quote from Peter Drucker,

Culture eats strategy for lunch.

You might have the best strategy, the best building, the best software, the best leadership, you might have the capital you need, but if your culture doesn’t get it, if your culture doesn’t nurture the workforce required to deliver the care, you’re toast.

We need to build skills among our existing team members and sometimes even ourselves, around conflict management, handling, confrontations, empathetic listening, and how we build trust, trust is constructed. It isn’t given from above. It doesn’t come upon us like amazing grace. Trust is the result of specific things that individuals do between each other and within intact workgroups.

And if you’re a team, don’t trust your leadership. If your teams don’t trust each other, there are signs, and there are cracks in the foundation. So, how do we cultivate systems and training? Well, for frontline caregivers, like CNAS and frontline caregivers and could be included in this diet as well.Is there a career ladder?

Career ladders for CNAs

I love the idea pocket promulgated by Lori Porter of Directors of Nurses. Do you have a Director of Nursing Assistance?Are there CNA specialists? People caring for people with dementia, or those who are orienting new staff or those who are designated as family liaison for those families that are grieving? For example, those families who haven’t been able to see the individual that they’re related to within the institution, because it is covered for other reasons.

So, there are systems that we can engage with our employees that show these frontline, that show these frontline caregivers, the respect they deserve and assign value to their roles when we too often aren’t able to offer them value in their paychecks. So, with that, I’m going to answer your questions.

Question 1 

How did we do this with no budget?

Most of the suggestions, I’ve offered, the resources are available either at no cost or very low cost. The suggestions that I made for, from the Society for Human Resources Management, that Scherm.

And there’ll be a citation to sherm in the Exercise Society of Human Resources Management. There’ll be a reference to several of their resources in the slide deck, and I believe they are also cited in our, on our website. So, all of the things that I’ve suggested can be undertaken at low, no, or very low cost.

The issue is, you, as operations managers and leaders, and I didn’t get to look through the list, people are signed up, and most of you are operational, supervisors, managers, even owners, and operators, there. The requirement is that you look at these issues as though you were being audited and you have to do them in your organization.

The requirement to have training for empathetic listening is every bit as important as the training for dealing with persons with Alzheimer’s and related disorders, these are important clinical dimensions on which you will be audited. If you consider the requirement for empathetic listening skills, if you consider the requirement for dealing with conflict and confrontation skills to deal with that, If you consider that part of your systems based auditing, you would find the time, make the time to locate the resources, and to deploy those resources within your operations. All of this can be done. They’re at no or very low cost.

Question 2 

Have you any experience with offering incentives to staff members who refer individuals who are hired?

Yes, I have quite a lot of experience with this, both positive, and that’s positive. And here are the issues with. Referral bonus: So, this is a cash incentive paid to an existing employee Who refers a non employee to your organization who is then subsequently hired?

So those types of bonuses must be managed very, very carefully. They have a systematic way of backfiring, and here’s how they backfire. You have, for example, a large group of very loyal, long term employees. One of those individuals’ decides that, oh, yeah, I know two people I could refer to. And I could get referral bonuses.

So she refers, and indeed, those two people are higher, and she receives those two referral bonuses, The other long term care employees, who did not put their social equity at risk by referring a prospective employee, those other two employees, will, one of them, almost guaranteed, will feel. Hurt will feel loss. We’ll have an unpleasant experience of, well, she got that money. How come I didn’t get that money? I referred somebody once before, and I’ve never gotten anything for that.

So the equity perceived equity, not just the system’s equity, but the perceived equity of these things needs to be managed very carefully. And the risk is that if you’re working in an environment and most nursing centers have quite a lot of employees, assisted living residences have quite a few employees, the culture, the rumor mill, the comments, the water cooler talk, can turn very negative, very fast. And if you’re working in a union based environment, it can get even more complicated.

So my experience, and thank you for the question, Anne. My experience with offering incentives to staff members is that it’s a very good idea.The other thing is that non cash incentives are more difficult to manage, but often have greater attraction to exactly the psychographic socio graphic whom you want and are less prone to create that kind of backlash. So I’d like none, cash based, or hybrid incentives, way better in one more thought about incentives.

If you’ve had a referral bonus incentive program in place, for some time now, cancel it, cancel it publicly, go through the Process, because what the research shows very, very clearly, is that incentives, all kinds of incentives, where out people become inured to them, they get, they just don’t see them anymore. So in order to rejuvenate them in order to re-energize Them, it’s necessary to go through the process of publicly canceling it. Reconstituting it and then re offering it again, and I would do that at least twice a year, or your employee incentive program.

Question 3 

Grant more frequent open quote revue, close quote, meetings sound good. But if you keep asking what employees want, isn’t that opening the candy store and setting you up for having to tell employees that they can’t keep having more, even if you want to give them more dollars, responsibility.

Well, thank you for that question. It’s a great question, and the answer is, no. What this question portrays is your perspective on the process and I’m attempting to shift that dynamic in it from your point of view. These quote, unquote, a performance appraisal review be attached to an expectation of compensation review.

I would like you to disconnect those to uncouple those cars, because performance appraisal should be just that. And pay rate review should be just that and should be distinct and separate, both in your eyes and in the supervisors’ eyes, and in the employee’s eyes and accomplishing that requires saying it, doing it, saying it, again, doing it again, saying it over and over again. If you’re listening to what your employees are telling you,  about job flexibility, about the location of supplies, about the factors that drive their ability to do their jobs effectively,

It’s almost an on ending list of small changes that can be made, and when those changes are made attributed to the feedback from employees, that the positive cycle of change that must be developed in our environments if we’re going to shift this culture.


Stackpole & Associates is a marketing, research & strategy consulting firm focused on healthcare and seniors’ services markets. Irving can be reached directly at

Marketing, research and business development consultant in healthcare, human services and senior living.

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