Few issues can throw a senior care provider off center more than the unexpected retirement of a valued nursing director, the loss of a beloved nursing aide to an outside employer, or a series of futile efforts to attract talent.

Staffing issues affect practically every facet of a facility’s culture and daily workings. But as successful operators can attest, there are ways to find balance, even in uneven times.

Top long-term care executives and professionals shared both their most vexing challenges and greatest successes during a special McKnight’s roundtable discussion in October, sponsored by Essity, manufacturer of TENA continence care products. Probing discussions covered workforce, caregiving and other top issues. 

Tipping Points

Rising resident acuity is a leading stressor, and it couldn’t come at a worse time for providers already struggling with unprecedented staffing challenges. A great deal of on-the-fly modifications are needed, experts said.

“We need to be prepared to give care everywhere,” said Blake Gillman, vice president/director of post-acute care services for Life Care Services. “It’s as much a challenge as it is an opportunity.”

Staff vacancies are at disturbing levels in many locales. As recently as early 2017, there were at least 22,000 unfilled new jobs in senior care, including skilled nursing, the Bureau of Labor Statistics says.

The first task is to find the workers; the second, to keep them.

That’s why providers that include Des Moines-based Lifespace Communities are using strategies like tying staff retention to executive incentive compensation, said Sara Elizabeth Hamm, DNP, RN, the company’s senior vice president of successful aging & health services. 

“So many large companies have incentive programs based entirely on occupancy, and that needs to change,” she told fellow roundtable participants. 

Chronic wage pressures are impeding efforts to recruit and retain staff.

Courtney Bishnoi, senior director of quality for the American Health Care Association, said one key to combating sluggish wages is providing meaningful work.

“If you’re a CNA and your job is about providing care and your career path is about moving up to being a nurse, you’re not going to leave your job to work in fast food,” she explained. 

Workplace violence and bullying, compounded by caring for growing numbers of mentally ill residents, are other powerful factors straining staffs.

 “If we do not support our staff and hold patients accountable [for violence], then we have failed them,” said Tambria Turco, vice president of clinical operations for Covenant Care.  

Participants were quick to point to leadership failures as a major cause of many staffing problems.

“In this industry, we often see middle or unit management not being well equipped to become managers,” said Bishnoi.

Deep dig for solutions

Participants eagerly shared innovative strategies that have helped them overcome staffing problems.

Hamm, for example, said Lifespace Communities recently recruited an undergraduate fine arts major to provide activities services to residents in exchange for room and board. Gillman added that Life Care Services routinely partners with universities and high schools “to catch potential workers in advance of moving through their career.”

Retention often is sabotaged from the start because hiring managers are looking too much at resumes rather than the people behind them, the panelists agreed.

Nexion Health Management battles this by employing an “unbox me” approach, according to Tara Roberts, vice president of rehabilitation and wound care services.

“We try not to get hung up on people’s certifications or letters behind their names and focus on their talents and interests as human beings,” she said. 

Covenant Care takes it one step further by viewing candidates’ lives beyond work hours.

“Our belief is to integrate people into our organization without looking at particular roles or titles,” Turco said. “While we all may come into a facility or organization with a specific title, it’s really more about who we are. We are community leaders. We are PTA members, boosters, church members. Capitalizing on this instead of pigeonholing people has created a great deal of success for us.”

Successful providers are beginning to find a wealth of talent right under their noses.

“Recruitment isn’t successful if you are constantly turning people over. The best place to look is inside first because it’s as important to retain as it is recruit,” said Bishnoi. “The message we need to convey is that long-term care is a place you can enter with very little training and grow your career path and socioeconomic status. This is not something every industry offers.”

Another benefit from recruiting within: Your employees should be immersed in the organization’s culture.

“Many DONs started out here as nursing assistants or unit managers. We now have these young vibrant people as CNAs wanting more and more,” said Stacey Merritt Hord, senior vice president of clinical operations for SavaSeniorCare. “You have to be constantly thinking about career progression.”

Julie Anderson-Black, vice president of business development and managed care relations for Windsor SNF Management Company, agreed: “The more we can value our staff and mentor and take people we see as leaders from a CNA on up, that’s where the culture shifts and changes and the satisfaction for the patients really is taken up to a different level.”

The same philosophy applies to recruiting managers and directors. Hamm said Lifespace Communities has been very successful with its internal staff development efforts, adding, “We have so many incredible individuals who started out in housekeeping or maintenance who now are leaders.”

Prioritizing engagement

It’s one thing to find the right employee. Keeping her or him is another. That’s why retention and engagement are so vital to staffing success. Making routine and regular engagement should be a high priority, panelists agreed.

One way is to engage staff on levels beyond their jobs, said Roberts, who has seen job satisfaction soar with a technique called purpose-driven mentoring. 

“We try to ensure any supervisor spends time with their employees to find out more about them beyond just being a CNA or a nurse or housekeeper,” she said. “When we do find individuals and are able to move them along their desired path, we then have to utilize them in their new roles, or they will move on.”

Successful providers never dismiss employee surveys.

“We are very passionate about knowing where our workforce sits as far as job satisfaction,” said Gillman, who noted a recent survey indicated less than half of Life Care Services’ staff said they felt they could call any co-workers friends. The company is now working with employees to build and identify more meaningful co-worker relationships. 

Hamm said Lifespace Communities routinely surveys staff to identify whether they’d recommend the organization to their friends. The results can be revealing and compel changes.

Successful companies have found empowerment effective.

Consider Windsor SNF Management, which created grand rounds for lower level clinicians at its facilities. Much like conventional grand rounds with DONs and physicians, interdisciplinary grand rounds give frontline caregivers such as aides and nursing assistants the ability to engage with residents on a higher level, and provide meaningful feedback on important, sometimes, critical, resident care issues.

Anderson-Black said the program imbues staff confidence, and contributes to the organization’s success in reducing rehospitalization rates. 

“When soliciting feedback during these rounds, we’ve taken it a step further and this creates a lot of satisfaction and most importantly identifies value and respect.”

Anderson-Black’s co-worker, Heidi Capela, vice president of clinical services, has had similar success with a program called the “DON Council,” a panel of 13 nursing directors across the company’s campuses that empowers participants to weigh in on a variety of issues, including assessing supplies and equipment. The company also has certified more than 200 nurses as wound care specialists.

Empowering caregiving staff in product selection, in fact, has reaped many benefits, roundtable participants pointed out. Nowhere is that more evident than incontinence care, a field that often finds science clashing with practice.

“It’s so important you have your nurses engaged in decisions about incontinence care,” said Hamm, who worked with staff to develop a clinical advisory committee that selected all of the products, from basic skin care to incontinence care, while working with vendor wound care experts to develop standardized formularies. 

One reason for the program’s success was flexibility in recognizing the nuances of each facility’s practice guidelines around incontinence care. 

“Sometimes each community may have a very different protocol and quality perspective while being good stewards of our financial resources,” Hamm said.

Empowering lower level clinicians has been key. 

“Rather than making decisions at the ‘ivory tower’ level, they do what they know works for them,” said Capela. “It seems small, but empowering staff to choose the products makes such a big difference. You have their buy-in. It’s invaluable.”

Because when employees care, care improves. Buildings become more home-like and a good reputation grows.

“If you walk into the front doors of any senior community and the first thing you notice is the smell of urine or feces, they shouldn’t be in business,” Hamm said. “That is straightforward poor care. That is nothing more than poor care or inadequate staffing levels and with the products that we have today and all the resources and technology that should not be happening.”

Keeping engaged 

Long-term care leadership must find better ways to give staff the tools they need to do their jobs. It’s become increasingly difficult in an age of declining and unpredictable reimbursement.

Everyone has witnessed supply hoarding, which even the most qualified caregivers do at times in order to ensure their residents get the care they need and deserve.

Bishnoi believes the real culprit isn’t necessarily money. 

“The problem isn’t the supply closet or the surveyor,” she said. “The problem is a breakdown in communication to get more supplies. If staff is telling their supervisors they need more resources and the supervisors don’t care, they’re naturally going to get frustrated.”

Merritt Hord agreed. “Leadership has to set the standard. What demotivates someone is not feeling important, not feeling valued or listened to. Key things for senior leaders at any facility level is to listen and engage with your CNAs and frontline staff and ask why they are hoarding.”

Acute, but not cute

Nothing will challenge staff more than having to deal with sicker residents in the years to come.

“We’re taking med-surg patients but we’re not staffing at med-surg levels, and CNAs are the primary caregivers,” said Anderson-Black. “I see that as a huge opportunity and a challenge that’s rather daunting because the patients are going to get even more challenging than they are today.”

Gillman, like others, openly embraces the challenges facing senior living providers today.

“What we need to do is clearly identify the rules of the road, engage employees in something that’s exciting for the future and then drive quality where people stand. If we can do that, then this industry is going to be wildly successful.”