The long-term care sector, reeling from one crisis to another because of the pandemic, is in the midst of the worst staffing crisis ever.
We know this empirically, because long-term care centers are unable to admit patients or residents because they are unable to staff up to meet those patient’s needs. More information about this long-term crisis is becoming known.
The Centers for Medicare and Medicaid Services (CMS) recently began to publish data regarding staffing in long-term care centers in the United States. While there will always be questions about a first publication, the information is startling. The median turnover rate among all nursing staff (including licensed nurses and aides) is 52.4%, with the registered nurse turnover rate almost 48%. Several questions emerge from these shocking data, perhaps the most compelling is: “Why?” Many of the reasons for this debacle are well understood. But more importantly, the question of the moment is:
What do we do now?
This workforce contraction will continue to have negative consequences not just for managers and operators, but also within the healthcare and social safety-net systems in our communities. And congregate, long-term care providers are often among the largest employers in the communities where they’re located. So we need to act quickly and constructively.
First is “scheduling for survival.”
Matching the need for workers on particular shift with who is available is becoming a nightmare for schedulers and managers. The pandemic severely reduced the number of nursing home occupants, so managers are trying to plump up occupancies. But trying to admit and / or care for patients, with a wary eye on the putative regulatory consequences of staffing errors is exhausting. The drought of available worker has resulted in a steep decline in SNF & HHA admissions and a raft of nursing home closures. This in turn is creating a backlog in hospitals and in the community, further hampering what had been a barely functional system.
Secondly, managers must focus on retention. Historically, the supply of workers in nursing homes was relatively stable and abundant. The historical supply of low-wage, frontline employees for nursing homes has dried up. No longer can turnover rates of over 50% be tolerated. This is far more easily said than done. Staff retention requires significant management and supervisory attention, and this resource is in short supply due to staffing shortages; something of a Catch-22 .
Third, recruiting employees at this time is difficult. This economy has extremely low unemployment, and other major employers are heavily recruiting, offering major incentives that siphon-off LTC candidates. These factors, combined with COVID-19 related hesitancy in the workforce makes recruitment a nightmare.
Let’s start with retention – keeping what we already have. What W Edwards Deming would call a “controllable defect” is the unsustainable and extraordinarily high rates of frontline workforce turnover in long-term care.
Why they leave
Turnover rates among frontline workers in long-term care is 50 – 90% every year. The reasons healthcare workers leave their jobs are varied and have changed over time.
These reasons can be parsed into these domains:
The culture in any organization refers to “intersubjective reality”, or the unspoken rules that govern behavior and frame perceptions of, and attitudes toward the organization and the work. The culture in most long-term care environments sucks, frankly. Before you get defensive, and say “Not at my facility!”, ask yourself if you know the name the woman who works in the kitchen 3 – 11, how many children she has and the name of her beloved pet. Some of you do – congratulations. If you don’t, you’ve made my point; keep reading.
Fortunately, there’s a lot we can do to almost immediately build a better culture within our organizations. The single most important step is to ramp-up the communications, and specifically to listen. This can be done at many levels. Examples include but are not limited to management by walking around, where you actually stop, ask, and listen. Interestingly recent research into MBWA that the behavior itself management walking around) can often be seen as intrusive and unproductive by employees. Even if you’re painfully shy, just showing up and listening changes the culture for the better.
Another important way we listen (or don’t) is through surveys. Whether simple or elaborate, asking employees and then utilizing their feedback helps to build trust and demonstrates that management believes , and that what is being said to you is important.
Various representatives of long-term care industry keep telling the media and speaking out about the poor rates of pay for frontline workers. They are pleading for higher payments from Medicaid. The history of minimum wage compensation in long-term care, however, goes hand-in-glove with a history of poor work environments and the treatment of frontline workers as fungible, replaceable means to an end. The continuous refrain, “Give us more!” creates the wrong message, publicly and politically. The “victimhood” created by this message within our organizational cultures has a negative result.
The reality among the long-term care workforce is that most of them are asset limited, income constrained and employed (ALICE) – often in two jobs. Recent article by KHN, an affiliate of Kaiser Health News, described the situation in Kentucky/Ohio where Amazon was attracting low-wage, long-term care workers with compelling offers of much higher pay and better benefits. An organization like Amazon can pass inflationary costs on to consumers; long-term care providers cannot. Why would an employee stay working in a nursing home or home health agency when she can earn $2.00 even $5.00 more per hour? Some will, and it would be extraordinarily valuable for us to learn why. How can we do that? By asking and then listening.
Employment in long-term care has often been seen as a transitory or segway kind of job. The local nursing home is convenient, offers employment in a variety of shifts, and has a very low skills threshold. Some of the low-wage jobs in nursing centers will always be filled with these employees, however in the current employment environment these individuals often at higher pay raise and better benefits. So, there are a number of employees in our organizations who will depart after some time with us to move on in their lives and their careers. This type of turnover is expected and can be planned.
Too often, healthcare workers quit because of their poor relationships with their supervisors, or the lack of relationships among their coworkers. This is an empirical fact based on years of research. It is a particularly costly oversight among long-term care managers and operators. Having friends at work, feeling that people listen to you, and knowing that someone at work cares about you are “soft” employment dimensions with undeniably hard results. When these three dimensions are rated poorly, turnover is higher.
Why they stay?
As was said above, workers too often quit because of poor relationships with their supervisors and their coworkers. But the inverse is also true; frontline workers stay in jobs despite better opportunities elsewhere because of the relationships that they have built, or which have been nurtured around them. This evidence is equally compelling. Frontline workers in healthcare and in long-term care will forgo potential raises and other compensatory benefits because of relationships. Managers and operators can leverage this fact by not only encouraging supervisors and coworkers to build and maintain supportive, comfortable relationships, but also by measuring supervisors and managers based on their effectiveness at nurturing relationships. Remember, “What gets measured gets done.”
Why they take these jobs
Recruiters have had a very profitable two years. The demand for frontline nursing staff, in particular has been extraordinarily high, and agencies and recruiters have stepped into this surge in demand with gusto. Our research on why frontline workers in long-term care take jobs shows that access, convenience, flexibility and a personal referral are the most important factors. Each of these has many possible dimensions to leverage, but at a time when recruitment of frontline workers is so difficult, it is surprising to see how operators and managers do not take advantage of these facts. For example, access and convenience include physical location and public transportation. This would call for promotions and advertising in the neighborhood, on the bus lines and in the stores frequented by our target demographic.
Another glaring omission by managers and operators among the recruitment activities is the tokenism of the employee referral programs. Remember that a personal referral was identified as an important reason why many frontline long-term care workers were originally interested in and ultimately accepted the job. So having an employee referral program in your organization, especially in the current recruitment environment is critical. We know that to be successful, the “program” must not be static, but must be varied over time and with different incentives for the referring employee. Variety and variation of the incentives are more important than the size or dollar value. This is not a “referral bonus”, but a referral incentive. A fixed or flat amount per referred and hired employee turns your staff into headhunters – not relationship builders.
Given the macro and micro economic factors, the political forces at work with the primary intermediary (CMS) and the overarching, indelible negative metaphor within long-term care, especially nursing homes, many will not make it. My hope is that intelligent managers and operators will use the best evidence-based insights to endure through what will be a difficult period.
Join us on Tuesday March 8th, The Long-Term Care Staffing Crisis: Intelligent Responses. Facilitated by Irving Stackpole, with Lori Porter, National Association of Health Care Assistants (NAHCA) and Dr. Michael Wasserman, California Association of Long-Term Care Medicine (CALTCM).
Irving Stackpole is President of Stackpole & Associates, a marketing, market research and training firm at www.StackpoleAssociates.com. He can be reached directly at: firstname.lastname@example.org.
 Muoio, D. Staffing shortages force long-term care facilities to limit admissions, hire agency workers. Fierce Healthcare, September 2021. See: https://www.fiercehealthcare.com/hospitals/staffing-shortages-force-long-term-care-facilities-to-limit-admissions-hire-agency
 Varney, Sarah. Nursing Homes Bleed Staff as Amazon Lures Low-Wage Workers with Prime Packages. KHN December 23, 2021. See: https://khn.org/news/article/nursing-homes-staff-shortages-amazon-lures-low-wage-workers/
 Haunch, K. et al, Understanding the staff behaviours that promote quality for older people living in long term care facilities: A realist review, International Journal of Nursing Studies, Volume 117, 2021, 103905, ISSN 0020-7489, https://doi.org/10.1016/j.ijnurstu.2021.103905. See: https://www.sciencedirect.com/science/article/pii/S0020748921000377