Susan Misiorski

Last November, the Massachusetts Senior Care Association launched a quality jobs initiative. The campaign is a response to a trend that is impacting long-term care providers in many parts of the country: a dramatic rise in staffing shortages. Not only is it difficult to recruit new workers to frontline CNA positons, good people are leaving for “better” jobs. Massachusetts nursing homes are experiencing average turnover rates of 30% among full-time staff employed longer than one year; one in 10 CNA positions in the state is vacant. These high rates of turnover and vacancy inevitably undermine the ability of long-term care organizations to deliver quality care.

I had the privilege to address the association’s annual meeting, where the leadership announced its Quality Jobs for Quality Care campaign. In my remarks, I addressed the vital importance of quality frontline jobs to ensuring quality care in our nation’s nursing homes. That’s a theme that has been at the center of my work for the national nonprofit PHI for the last fifteen years. 

PHI, through its training and consulting work in cities and towns across the country, has helped hundreds of providers improve recruitment and retention of CNAs and home care aides by focusing on the key elements of a quality job.  

What are these elements? PHI has identified nine that we believe are essential to making direct-care work in nursing homes and home care settings viable career opportunities. These nine elements center on three basic themes: Compensation, opportunity, and support.

Compensation is straightforward, though sometimes one of the most challenging elements on which to make real progress. To attract workers to direct-care positions, these positions need to pay a family-sustaining wage and provide basic quality-of-life benefits, including affordable health coverage and paid time off. CNAs and home care aides cannot be left behind as retailers like Walmart and fast-food chains like McDonald’s raise wages to $15 per hour.

While better wages are essential to creating better jobs, higher wages alone are not sufficient. Quality jobs must also give workers meaningful opportunities to advance in their careers, to participate in decision-making processes, and to receive the training necessary to perform their jobs with confidence and success. PHI advocates not only for enhanced training standards, but for training methods that support adult learners to become skilled in communication and managing sometimes challenging caregiving relationships.

Support is needed from supervisors, managers, and administrators. This is the final piece of the quality-jobs puzzle. The vast majority of CNAs and home care aides truly love what they do, but unless they feel respected and supported in their jobs, they won’t stick around very long. (As we say at PHI: Workers don’t leave their jobs; they leave their supervisors.) Unfortunately, only a small percentage of the RNs and LPNs tasked with supervising direct-care staff have received adequate supervisory training. And when supervisors do not have the skills to support employees in building strong caregiving relationships and solving problems, turnover is high – and care outcomes are diminished.

For two decades, PHI has been teaching an approach to supervision that strengthens key skills so that supervisors are able to build strong relationships, reduce disciplinary action, and focus on helping direct-care staff to learn and grow on the job. The results: higher job satisfaction among both supervisors and direct-care staff, less turnover, and better clinical outcomes.

Our experience parallels that of the renowned long-term care expert Nicholas Castle, Ph.D. Castle’s research shows that nursing home staff that have a high level of job satisfaction produce better outcomes for residents – everything from fewer pressure ulcers to reduced catheter use.

These strategies to improve job quality require varying degrees of investment in terms of both time and money. But we’ve found that investing in the direct-care workforce is always worthwhile. Direct-care staff who are well-compensated, have the chance to learn and grow on the job, and feel respected and supported will inevitably produce better care outcomes than staff who are undervalued and poorly paid. Unfortunately, the latter scenario remains much too common. But PHI, which introduced the Quality Care through Quality approach to transforming long-term care 25 years ago, and the Massachusetts Senior Care Association, with its new quality jobs initiative, are trying to change that. Direct-care workers – and the people for whom they care – deserve nothing less.

Susan Misiorski is the National Director of Coaching and Consulting Services for PHI.