Lindsey Creapeau

We all know it – staffing (or lack thereof) is a critical issue in long-term care, now more than ever. Recruitment and retention of qualified caregivers are at the forefront of most of our conversations.

As academics who teach and support our field’s emerging leaders, faculty in the Health Care Administration program at the University of Wisconsin – Eau Claire conduct an annual applied research project related to a pertinent issue in our field. Without a doubt, our most recent topic selection came easily, with a focus on both leadership and staff perceptions on staffing challenges for certified nursing assistants (CNAs).

With our Administrative Residency students completing a year-long internship at skilled nursing facilities across the Midwest (and beyond), we had research assistants available to help collect qualitative data from 59 nursing home administrators (NHAs), 59 directors of nursing (DONs), and 295 CNAs. 

Students asked participants a series of questions related to what they believed to be the root causes of staffing challenges, what the top three things CNAs were looking for from employers, and what the top five most useful strategies, factors, programs or practices they’d seen in place to positively impact retention of CNAs. 

Now, most of us would read those prompts and respond with “higher wages.” Period. Yes, we absolutely know that funding and wages are an issue in long-term care, but we sought to determine whether there were other ways we could hang on to our employees. Caregiving is an incredibly tough job, both physically and mentally, and so “wages” are not our be-all-end-all solution.  Perhaps surprisingly, we found that leadership (NHAs and DONs) and staff (CNAs) responses were not in alignment in most of these areas.

Jennifer Johs-Artsensi

When considering overall staffing challenges, NHAs and DONs seemed to have four to five commonly mentioned issues: competition (other long-term care sites or even those in other industries), low wages, shortages of candidates to apply, the physically and emotionally demanding nature of the job, and low federal/state reimbursement. 

However, CNAs were more varied in their responses, suggesting there may be a broader array of potential staffing solutions than those upon which leadership is often focused. For example, CNAs themselves cited lack of onsite training and poor work culture as challenges, both of which could be improved upon without significant expenditure. 

So, what do CNAs want? All three stakeholder groups cited better wages (yes, we agree) and more appreciation. CNAs noted that a good work environment (e.g., positive, stable, consistent, honest atmosphere, “good culture”) and healthy relationships at work are important to them. Interestingly, DONs, who might be most responsible for influencing these areas, noted these as being important to CNAs less frequently than NHAs and CNAs did. Although NHAs recognized the importance of a good work environment, they rarely saw it as something contributing to their own staffing challenges. This may suggest that administrators understand the importance of the working environment but may fail to see it as problematic at their site. 

Two other areas of notable misalignment emerged related to what CNAs want from an employer. First, both DONs and CNAs recognized that emotional support (e.g., “someone to listen to me,” counseling) was desired, but NHAs either did not recognize its importance or were not aware that it was desired. Additionally, both leadership positions believed that a manageable workload (e.g., adequate staffing ratio) was important to CNAs yet it was infrequently mentioned by CNAs themselves. This may indicate that CNAs do not mind being busy at work, so long as they have assistance, resources and a team-oriented working environment.

Beyond wages, benefits and other ideas noted above, CNAs identified a plethora of ideas about what they and their peers particularly value from leadership, such as control over their schedules, better communication and an ability to have their voices heard – many of which do not have a price tag attached. 

Several other tangible practices were referenced regarding retention strategies participants have seen work well, including onsite training, career advancement paths, and mentorship programs. Interestingly, CNAs alone cited practical support as a retention strategy while neither NHAs nor DONs did, which is another potential avenue leadership could explore. Specifically, strategies they mentioned in this realm included on-site childcare, a food pantry, transportation to work, free meal/snacks during shifts and employee discounts.

Finally, and perhaps most importantly: several CNAs stated that their relationships with residents would “make them stay” at their place of employment, yet not a single NHA or DON mentioned the value of resident-staff relationships in reducing turnover.

The main takeaway from this study? CNAs have great ideas related to how they can be better retained (often at little or no cost) – leadership just needs to listen and keep an open mind.

The complete findings of this study can be found in the March 2022 issue of the Journal of Nursing Administration.

Lindsey Creapeau, Ed.D., LALD, FACHCA, is an administrative residency coordinator and instructor at the University of Wisconsin – Eau Claire. She can be reached at [email protected].

Jennifer Johs-Artisensi, Ph.D., MPH, LALD, is a professor and program director at the University of Wisconsin – Eau Claire. She can be reached at [email protected].

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.