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Retention: “Sticky relationships”

Retention: “Sticky relationships” July 26, 2022

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


Nationally, turnover in long term care is at an annual rate of 70 – 90%. Providers are threatened with penalties for failing to meet threshold requirements and are unable to admit patients when they do not have the staff to care for them. Furthermore, unemployment in most US cities remains below 4% so that job candidates are rare. We are in the midst of a painfully difficult staffing crisis in long-term care.

Faced with this situation, logic and good management discipline suggests that the first thing to do is stop or reduce turnover. This approach does not appear to be happening at the depth, breadth, and intensity needed. The sector needs to get smarter about employee retention and quickly! Long term care managers must prioritize keeping the employees they have by becoming employers of choice. Here is how.

Easy come, easy go

In the past, long-term care operators tolerated high levels of turnover because there  appeared to be an endless supply of low-wage job candidates. In most marketplace areas there has historically been an abundance of job candidates willing to take the difficult roles in long-term care because the jobs fit into their schedules, were convenient, or because they benefit  the candidates’ career plans. Based on recent changes in the job markets, these employment dynamics have vanished in most marketplace areas with little hope of return.  With recruitment so difficult, the focus must shift to retention.


The most important employee retention factors in service-based long term-care and healthcare environments are the relationships between and among the employee, her colleagues, and her supervisors.[1], [2], [3] Staff represents 60 – 80% of every healthcare and long-term care operating budget. Holding onto the staff who are in place is essential.  The cost of retaining staff is far lower than hiring new staff. With tight budgets, this approach makes operational and budgetary sense.


In a recent survey by OnShift, a human resources software provider, a representative sample of long-term care managers remain highly focused on recruiting (67%).[4] The obvious reason for this incongruous attention to recruitment rather than retention is that it has worked in the past. In previous labor cycle shortfalls, increased recruitment advertisements and activities, accompanied by some incentives, have filled all or some of the vacant positions. And then there are the economic recessions, which have driven more people into the job market, helping long term care providers fill vacant positions.

This somewhat effective, historical reliance upon recruitment to fill all too frequent job openings has obscured the fact that the work culture in most long-term care provider organizations is weak. During the pandemic there were widely publicized efforts to quickly change this disrespect of frontline caregivers with “healthcare heroes” acknowledgement programs. This “too little, too late” approach has been very thin balm on very deep wounds.

Where the rubber meets the road

There is enormous, incontrovertible evidence that employee retention is driven by relationships and theRecruitment in LTC culture that foster and support these relationships. What are the hallmarks of healthy organizational cultures? How do you know when relationships  are high quality, or require more attention? Because “What gets measured gets done” – how do we measure relationships and their quality? If a long-term care operator wants to be the employer of choice in its marketplace area, what can be done to differentiate the operation on the inside, which will result in improved culture, and better retention?

As discussed in prior articles, creating better relationship measures can help managers understand how to improve communications. Improving communications  is the start of culture change!

Some best practices to create much needed culture change include:

  • Conduct a review of what you have done over the past few years to measure employees’ attitudes. Can you streamline the process and increase the frequency of measures?
  • Train for success. Every supervisor, every manager should learn how to conduct frequent, opportunistic observations of, and interactions with their teams and their peers. This training includes sensitivity & language, active listening skills, use of practical examples, body language & eye contact, conflict management and cultural sensitivity. Recording the observations and comments should be easy for everyone. Streamline processes to ensure that they continue to be used.
  • Reinforce key messages to supervisors and staff that the purpose of employee evaluations is to improve team collaboration and patient care – not to find fault or to judge.
  • Staff should measure and rate themselves first, then supervisors rate their direct reports on basically the same job-related dimensions such as skills, collaboration, adherence with policies & procedures and interpersonal skills. These two evaluation steps are followed by a conversation between the supervisor(s) and the direct report.
  • Anticipate push back and train for it. Conflict management training is crucial to success.

Holding up the relationship mirror

recruitmentTo meaningfully change relationships, improve the culture and retain necessary workforce, an honest appraisal is needed by managers and supervisors of relationships between and among themselves and others. These “soft” measures have not, historically, been the focus of managers within long-term care organizations. Too often, attempts to change cultures in long term care are prescriptive. That is, “It’s for them…” rather than “We’re all in this together…”.

The relationship review process includes looking at issues like

” …acceptance, respect & admiration, understanding, friendship & companionship, ease in communication, sharing, caring & concern, wanting to please, striving for mutual goals, interdependence, pride, trust, belonging together, similarity of thought, indebtedness, gladness & peace of mind, expansion, and reciprocity”.[5]

Notice that these have nothing to do with how much you pay, the job title you give employees, or pizza on Friday. It has everything to do with the type of environment where human beings either struggle to survive, or flourish.

Which relationships? 

According to the UK-based organization, Skills for Care, the categories of relationships that affect culture in long term care are consumers / clients  (patients), friends and family;  staff & managers (caregivers); those from other organizations (advocates), including ombudspersons, attorneys and inspectors, and; volunteers and community groups.[6]


All of these groups have relationships that contribute to and are reflective of the culture in your organization. At a practical level, you need to start somewhere, and the best place is to evaluate the relationships between supervisors and staff.

How do you begin to evaluate relationships?

There are methods used in other sectors (hospitality, education, etc.) to measure the quality of relationships within work groups, which can be adapted for long term care. [7]

For example, staff engagement / satisfaction surveys can include questions such as:


And of course, once the survey feedback is collected, a clear eyed and objective assessment needs to occur. There is no more powerful tool to fix relationships than candid feedback, and in long term care organizations this feedback has not been sought and it has even been discouraged.

The personal mirror; assessing your own relationships

In keeping with the “We’re all in this together” theme, executives, managers, supervisors, and otherrecruitment organizational leaders would do well to evaluate their work-related relationships and to then solicit feedback from their boss, peers, and direct reports. Where to start?

Here is a simple model for categorizing your relationships into six different types: [8]

  1. A dependent relationship, based on trust and reliability;
  2. Positive involvement, based on care and communication;
  3. An average, functional relationship;
  4. A dysfunctional relationship, characterized by low inclusion, anger, and difficulties;
  5. An anger-based relationship, characterized by frequent conflicts;
  6. An uninvolved relationship, characterized by a low level of communication, absence of care, and (possibly) anger.

This grid can be used to fill in the full, 3600 profile:


If leadership honestly reviews this array of possible relationships, the review can be a way to support (types 1 – 3) or help repair (types 4 – 6) the matrix of relationships. At least the process will push management out of their comfort zones and create way to talk about relationships at work.

Categories at work

recruitmentNo one individual is exactly the same as another, and when people work together the effects often depend on the affects. Differences can be strengths in a work group, or they can become polarizing and destructive. The goal is to identify and support relationships that work and address those relationships that need work.

The tool below compares the psychological or behavioral profiles of supervisors, how these profiles are recognized in planning, performance, and method and – importantly – the likely impact each supervisor profile has on their direct reports. This tool also considers whether the staff person (“Report”) is “confident and skilled” or “insecure and less skilled”.[9] The reports’ relationships area is the key outcome; the goals should be balance, consistency, and alignment.


The purpose of such a categorizing method is not to portray one personality profile as better or worse than another, but to prompt leadership to look at relationships, evaluate them and their outcomes so that relationships at work can be managed, leading to higher levels of retention.

From “fuzzy” to fundamental


Retention of mission critical staff members has to be a top priority for every long-term care manager. For far too long, holding onto mission-critical human resources has been delegated or left unattended until the next urgent staffing crisis. In the past, managers have been able to recruit needed staff in their marketplace areas, and therefore avoid the worst impacts of shortages. Those days may be gone forever. The sector must innovate and differentiate by becoming an employer of choice, first for existing staff, and in turn for prospective, new team members.

In the next article, we’ll look at innovative recruitment methods and how we can “get them in the door”.

Irving Stackpole is President of Stackpole & Associates, a marketing, market research and training firm at He can be reached for direct consultations at: or at +1-617-719-9530.

[1]Harris-Kojetin, L., et al. Recent Findings on Frontline Long-Term Care Workers: A Research Synthesis 1999-2003. Institute for the Future of Aging Services, ASPE. May 2004.

[2]Riggs, C. Jo MSN, RN; Rantz, Marilyn J. PhD, RN, FAAN A Model of Staff Support to Improve Retention in Long-Term Care, Nursing Administration Quarterly: Winter 2001 – Volume 25 – Issue 2 – p 43-54

[3]Fleig-Palmer, M. M., & Rathert, C. (2015). Interpersonal mentoring and its influence on retention of valued health care workers: The moderating role of affective commitment. Health Care Management Review40(1), 56–64.

[4]Senior care survey report: workforce 360. Employee Burnout, Fear & Safety Concerns Impact Recruitment & Retention in Senior Care. Fall 2020. OnShift. See:

[5]Garthoeffner JL, Henry CS, Robinson LC. The Modified Interpersonal Relationship Scale: Reliability and Validity. Psychological Reports. 1993;73(part):995-1004. doi:10.1177/00332941930733pt14

[6]Adapted from The Care Certificate Workbook, Skills for Care, Lynton House, London. See:

[7]Fletcher, G. J. O., Simpson, J. A., & Thomas, G. (2000). The Measurement of Perceived Relationship Quality Components: A Confirmatory Factor Analytic Approach. Personality and Social Psychology Bulletin, 26(3), 340–354.

[8]Adapted from: Pianta, R. C. (1994). Patterns of relationships between children and kindergarten teachers. Journal of School Psychology, 32(1), 15–31.

[9]Adapted from Pianta, R. C. (1994) op cit

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

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