The pandemic has hammered long-term care on numerous operational fronts, from testing the field’s infection control capabilities to influencing occupancy rates. One of the hardest-hit areas has been staffing.

For an industry that grapples with staffing retention and recruitment issues during ordinary times, COVID-19 has dealt the equivalent of a knockout punch.

“When you struggle with turnover, it’s chronic staffing problems,” explained Kristin Baird, RN, BSN, president and CEO of the Baird Group, a healthcare management consulting firm. “It puts a burden on the people who stay, and on the leaders who have to scramble to fill spots and maintain the quality of care. You layer COVID on top of that, and [organizations] are having to be uber-cautious that if there’s known exposure, they have to send people home or keep people away from the residents. It’s added insult to injury in an industry that is already struggling from high turnover.”

Kezia Scales, Ph.D., director of policy research for PHI, a nonprofit geared to offering information and advocacy about frontline workers in post-acute care, noted that the staffing shortage “is exponentially worse right now.”

A PHI report released in September on key facts about direct-care workers underscored her point. It stated that 1 in 6 nursing homes (17%) report a shortage of nursing assistants. 

The current workforce squeeze stems from the toll that fighting the virus has taken on staff, according to the American Health Care Association/National Center for Assisted Living. “Some long-term care workers have become ill or are quarantined and cannot return to work, while others cannot work due to a lack of childcare options,” a spokesperson said.   

Robyn Stone, Ph.D., senior vice president of research for LeadingAge, the advocacy group for nonprofit providers, pointed out that the pandemic has hurt long-term care staff in two ways: It created risks not only on the job, but also in their communities. Many workers are poor, immigrants and people of color.  

“You sort of had a double whammy in these settings,” she said. “You have people who are working with a high-risk population and people coming from a high-risk population.” 

Finding answers 

As a result of the staffing need, facilities are scrambling, Scales said. While a federal blanket waiver that allows facilities to postpone a critical training requirement for certified nursing assistants has helped to alleviate some of the frontline shortage, it has not been a panacea. It also carries the risk of bringing people into a “dangerous and challenging situation without a lot of training … and limited support on the job,” she said.

Facilities are instituting a range of other measures to help stop the bleeding from frontline turnover, she said. These include implementing hazard or appreciation pay to raise compensation and offset the job challenges. Facilities also are providing training for the use of personal protective equipment; stress management and grief support to CNAs, who are dealing daily with resident sickness and death; and giving other in-kind support, such as free meals on shifts and food to take home.

Stone added that the smarter organizations are paying higher wages, acknowledging career pathways, focusing on workforce improvement, and putting together resources to address challenges regarding transportation and mental health.

“This is such a labor-intensive sector. The ones that do it right recognize, ‘It’s the people, stupid,’” Stone said. “You can’t have a healthy organization without a healthy workplace.”

At the end of the day, organizations need to focus primarily on retention, as opposed to recruitment, she noted.

“You can’t keep recruiting with a lot of churning of staff,” she said. “The more you have turnover, the less you can retain.”

The communication piece

One of the most important tools facilities can use to improve retention is communication, according to staffing experts. Feeling a lack of support can lead an employee to leave a job, said Nancy Anderson, RN, MA, senior vice president of engagement solutions for Align, a firm that provides solutions to increase employee engagement with seniors.

She likened the emergency situation nursing homes are living through now to when she worked as a nursing assistant in Duluth, MN, during a snowstorm. Working short-staffed, the “we’re in this together” spirit was pivotal.

“That feeling is possible, but it really does come down to the message of that management team,” she said.

She suggested that organizations review their communication processes to help employees feel more informed regarding the situation with PPE and evolving testing requirements.

“What processes do you have in place to routinely and consistently communicate with employees?” she offered. “It’s not just the newsletter you might produce on a monthly basis or all-staff meeting once a month. It’s two-way communication that is more essential than ever right now. That can be through employee rounds; that could be the best way. The managers are actually getting out onto the unit, into the departments and talking to employees.”

Creating a strong management team is just as essential.

“The strength of that team will absolutely impact the retention and engagement of employees,” Anderson said.

She emphasized that taking the time to demonstrate to employees that they matter goes further than more temporary fixes.

“The gift cards and pizza parties and potlucks are fun things to do, but that’s not the stuff that makes a difference,” Anderson said. “That’s not the stuff that lasts. It comes down to basic human connection and how people are treated.” 

Concerns for the future

Meanwhile, the future of long-term care staffing post-pandemic looks murky. Several concerns loom. If the blanket waiver for CNA training expires, for example, that could mean a significant hit to the labor pool. Then there is the public relations damage to long-term care as a result of the pandemic.

Scales of PHI questioned whether people in the long run will take jobs in long-term care, knowing how challenging they can be “and often unrewarded they are, given the level of risk.”

Stone agreed that this is the big question — and not just for frontline staff: “As part of figuring out the solution of the evolved nursing home and the evolved long-term services and supports system, how are we going to support and sustain a quality workforce so people are attracted and want to remain and grow in these jobs?” 

The pandemic may not be all bad if it leads to large-scale change, Stone suggested.

“It’s been an undervalued sector, and I think this has shed a light on that,” she said. “While some horrible things have come out of it, we also have the opportunity to do things differently.”

As part of the solution, certain universal repairs need to be instituted in long-term care in response to COVID-19, such as hazard pay, sufficient testing and access to PPE, Scales said.

There will be an impact on  recruitment and retention “unless we make some fairly significant changes to job quality for these workers,” she said.

Stone noted that the best organizations are looking beyond the widely used metric of staffing ratios to how staff is organized.

“I think we have an opportunity to see how space matters in allocation of workforce space, how work gets assigned, how people work in teams to mitigate some of the staff callouts that have happened during this process — because in a team environment everyone is accountable to everyone else,” she said.

In the long run, organizations that thrive will have learned how to be less transactional and more humanistic, Anderson said. That is, they have to be less concerned with “checking the box” regarding compliance issues and more concerned with nurturing people.

“The human aspect really needs to be front and center … to be successful as an organization,” she said.

From the October 2020 Issue of McKnight's Long-Term Care News