Researchers found that scheduling CNAs regularly with the same group of teammates reduced turnover by nearly 25%. 

If nursing homes capitalize on the results of the study, it could go a long way toward cheaply and effectively addressing the nursing home staffing crisis, according to lead author Kevin Mayo, PhD, assistant professor of finance and management science at Washington State University. 

“These findings suggest that managers may be able to leverage part-time CNA scheduling to reduce turnover,” the study asserts, “improving both the quality and cost of care.”

The study also found that giving part-time CNAs one additional hour of work per week could reduce turnover by about 2%. Turnover was increased both by too few hours worked and too many, however, so facilities need to be more cautious in this regard. 

Building cohesive, consistent teams is the most important factor to consider, Mayo said, but nursing homes should consider all aspects of the study to achieve the best results. 

“By both balancing working hours and maintaining consistent teams, healthcare facilities can greatly reduce staff turnover,” Mayo told Newswise. 

Between greater scheduling consistency and tweaking hours worked, the authors estimate that facilities can save 7% of their operating costs with greater employee retention. 

Nursing homes have already felt the pressure to employ more flexible, worker-focused scheduling in response to the staffing crisis. The results of this study suggest that there are large benefits to be gained from this approach, and at very low cost.

Greater retention should also lead to higher quality of care for residents. After analysis of their data, the researchers concluded that CNA turnover had measurable negative effects on care quality that could be eliminated by increased retention. 

The study, published in the journal Manufacturing & Services Operations Management, analyzed data for more than 6,000 part-time CNAs from 157 facilities. 

Other authors included University of Cincinnati Assistant Professor Eric Webb, PhD, as well as Indiana University’s George Ball, PhD, and Kurt Bretthauer, PhD.

A National Council of State Boards of Nursing study released in April revealed that up to 20% of registered nurses could leave the industry within five years. Critically, this includes a large minority of younger nurses, at a time when a proposed federal staffing mandate for nursing homes could drive up RN demand considerably.

Maryanne Alexander, chief officer of nursing regulation at NCSBN, called the developing retention situation a “crisis” at a Nov 9 panel of experts hosted by NCSBN.

“We have seen something that we have never seen before,” Alexander explained. “Twenty-four percent of those nurses that want to leave nursing have less than 10 years of experience.”

Karen Lyon, PhD, CEO of the Louisiana State Board of Nursing and one of the NCSBN panelists, agreed.

“A nursing shortage like this, either because nurses are dropping out or young people aren’t coming into the profession, is a very dangerous trend for us,” said Lyon.

Fundamental retention problems

Panelists agreed on the fundamental problems facing the industry. 

“When everyone does the analysis of the workforce issues, they come up with two basic reasons,” for shortages, said Beverly Malone, PhD, president and CEO of the National League for Nursing. “One is not enough nurse educators and the second is not enough clinical placements.” 

One major problem in nurse education is the ability to find good placements for students. The quality of clinical placements are impacted by the stress and burnout of veteran care workers. New care workers who aren’t given the time and personalized training to succeed feel left behind. And, in turn, veteran nurses struggle without their own reliable and plentiful support.

“A huge percentage of education takes place in the clinical setting,” said Eileen Fry-Bowers, PhD, dean of the University of San Francisco School of Nursing and Health Professionals. “When [currently working] nurses are fatigued or burned out, their ability to work with our students is reduced and many of our clinical agencies then say that they’re not going to take more students.”

Potential solutions

Lyon emphasized the need to match new workers with established frontline nurses to ensure they have a reliable safety net in the initial months of their careers. 

More efforts need to be made to improve facility culture and teach leadership skills to nurses at all levels, added Lavonia Thomas, nursing informatics officer at MD Anderson.

“We engaged in nursing transformation efforts based on feedback from our staff nurses,” said Thomas. “First off focusing on those that were hired in the last three years — because they were hired during the pandemic and needed to focus some of their skills — and then moving forward to those with more experience, and then to all nurses, because all nurses are leaders in whatever job that they hold.”

Additional training also needs to be backed up with more support for nurses’ day-to-day care duties, the panel agreed.

Thomas discussed the hiring of 10 new virtual nursing workers at MD Anderson. Following feedback from frontline nurses saying they wanted more support, the remote nurses have been guiding them on admission and discharge processes. 

“But that’s just the beginning, there’s so much potential,” Thomas said. “Nurses feel very rushed in everything that they do. And so having that person to back them up — where they can think, ‘I’m not taking you away from another patient’ — has been well received.”

Aside from this more agile collaboration, adding virtual nursing to its care practices has allowed MD Anderson to hire nurses who need flexible work schedules.

Recruiting, employee retention and the added pressure to support overburdened care workers have been major areas of focus throughout the skilled nursing industry. 

“I would say it takes a village to raise a new nurse,” said Fry-Bowers. “It takes practice, education, regulation, our clinical partners and our communities all working together so that they can go out and serve the public in a safe and confident manner while not sacrificing their own wellbeing.”

Cara Silletto, employee retention expert and president of Magnet Culture, addressed the other side of the coin at the LeadingAge Annual Meeting in Chicago.

Silletto reminded attendees of her session that current staffing issues have created a surplus of facilities in the process of hiring. At the same time, a savvy workforce is leveraging an abundance of online tools to seriously weigh their options. 

As caregiving professions continue to rely more on a younger pool of workers, they also have to reckon with a generation that has the confidence to change jobs. 

Younger workers have reacted strongly against the “stick it out” philosophy of their parents’ generation and have much less tolerance for unsatisfactory work conditions. “Now people say, ‘I’m not happy, I’m out,’” Silletto observed.

Because so many facilities are hiring, these employees can leave a workplace and be reasonably assured of finding new positions soon.  

Together, these factors lead to a “perfect storm” that makes employee retention extremely challenging, said Silletto. However, there are still many actionable steps that can address these problems.

“Even having 20% to 25% turnover every year is disruptive,” Silletto said. “So let’s plan for it. Let’s create a well-oiled machine that can operate in this environment that we’ve been dealt.”

Making employees feel heard

“We’re going to have to turn and look inside at ourselves in order to operationalize turnover,” Silletto said. In doing so, it’s important to not assume why workers quit. 

Employee retention is not always a simple issue of pay and benefits. Open lines of communication and respect are often equally, or even more, significant to workers.

Silletto suggested beginning any employee retention roadmap with a listening tour, emphasizing that the goal should be to give employees the freedom and safety to voice their concerns, not just focus on defending current practices.

“Understand that people will be intimidated by you being out on the floor,” Silletto told attendees. She also emphasized ensuring that everyone is being heard — not neglecting third-shift workers or others who may not typically get as much attention.

Setting sustainable work goals

Another key concept to consider is “scope creep” — the ways in which challenges in the industry have pressured employers to place increasingly demanding workloads on employees over time.

Silletto acknowledged the impact of these challenges — such as regulations, funding and the impacts of the COVID-19 pandemic — but maintained that recognizing and addressing scope creep is a crucial step in boosting employee retention.

“I need us to realize this scope creep has happened and now there are organizations out there who have unrealistic expectations for their folks,” she said. Asking employees to go above and beyond every single day can leave star employees feeling burnt out and regular, reliable employees feeling defeated.

Investing in managers so they can invest in workers

Scope creep has impacted management too, Silletto said.

“I have leaders in senior care who tell me, ‘Cara, recruiting used to be about 15% of my job, maybe 20%, and now 40% to 60% of my time is on recruiting, and onboarding, and all the job postings and hunting down no-shows.”

Even beyond the added burden for managers, this managerial scope creep takes away time that they could be spending on mentoring employees — a role that is only becoming more vital, according to Silletto. 

Due to generational differences, younger employees tend to want mentoring and frequent positive feedback as they learn and adjust to new roles. When managers have the tools and time they need to address these needs, they can act as a buffer between employees and challenges in the workplace — making sure that employees continually feel seen and supported even through those challenges.

Treating new employees with care

“The new hires are your greatest flight risk,” Silletto said, adding it’s vitally important to treat them with respect and care during onboarding. “The last thing we want is to give them the worst shift, or the worst grunt work, or the worst equipment.” 

Silletto warned against allowing hazing, or established workers treating new coworkers as second-class citizens until they’ve been on the job for an arbitrary period of time. 

While it might be tempting to gloss over such behavior if these established workers are vital to the facility, it’s important to count the costs of the behavior as well. A toxic work environment can directly lead to the degrading of a culture of genuine care in the facility and to a revolving door of employee turnover.

The difficulties of finding time and funding for employee retention programs are clear, but Silletto suggested that the cost of not implementing them could very well be higher. 

Onboarding is inherently expensive and demands critical time and resources from management. Losing workers due to burnout or a toxic work environment also keeps facilities reliant on new, untested employees instead of allowing experience and expertise to grow over time. 

Addressing the concerns of both employees and management could be a key roadmap to addressing the issues of both cost and staffing.

While employees last year clamored for more co-workers to improve their job satisfaction, the most desired change this year was a higher salary, with more than half of survey takers choosing that option. And despite three-quarters (75.1%) reporting being “somewhat satisfied” or “very satisfied” with their current jobs, almost one-quarter (22.6%) said they were “not so well paid,” or “not at all well paid.”

The 2023 survey drew more than 500 responses from directors of nursing and their assistants, and administrators and their assistants. They sent mixed signals about the meaningfulness of their work, their willingness to remain on the job and the changes today’s employers need to adopt to keep them.

Overall, the share of workers “very satisfied” or “somewhat satisfied” with their current job rose about 3% from the 71.9% mark of a year ago.

Cara Silletto, president and chief retention officer of Magnet Culture, said she’s hearing from clients that some staffing stability has been gained over the last six months. But she cautions that any relief from the workforce shortage shouldn’t be viewed as a return to pre-COVID normalcy. In fact, she believes many nursing home leaders see themselves with a new baseline for staffing — one that is leading them to demand better pay even after years of solid increases.

“On this particular question saying more staff will solve my problem, they’re now rolling their eyes and saying, ‘Yeah, yeah, that’d be nice,’” Silletto told McKnight’s Long-Term Care News after reviewing results. “That shrinking staff is why I think they just want higher salaries because they’re going, ‘We’re gonna have to deal with this churn. And so I just need more money because I am never fully staffed. I am never going to get caught up. I am never gonna be not trying to fill tonight’s shift.”

Staffing a ‘smidge’ better

Katie Piperata, a workforce engineer with 15 years’ experience recruiting for skilled nursing, counters that the boost in satisfaction rates and some of the other positive findings from this year’s survey are reflective of the labor crisis “getting a smidge better.” 

She noted the negative “trickle-up” effect of a DON being routinely called to the floor to cover for missing nurses or aides. Administrators then have to step in on some of the DON’s duties, a reality that has hurt satisfaction among both categories of workers in the COVID era.

At National Healthcare Associates, which operates 33 facilities in the Northeast, leaders are trying to combat inflationary pressures with fair salary increases and a culture that prioritizes retention. They’ve seen increased demands for raises and higher asks from new candidates, says Anthony Scarpino, the company’s vice president of talent acquisition. 

“It’s a factor of the rapid inflationary growth of salaries,” he told McKnight’s. “Your salary may fall behind in a single year.”

That could be one explanation for the 52.2% of respondents who said a higher salary would most improve their job satisfaction. That broke down to 51.3% among DONs and 52.8% among administrators.

Just 17.5% of survey respondents said they were “very well paid,” a finding that remained static year-over-year, despite recent raises that exceeded historic averages nationally. Nursing home administrator salaries averaged $127,763, up 3.6% from $123,324 in 2022. Directors of nursing saw their average pay climb 4.67% from $103,954 in 2022 to $108,889 this year, according to the annual HCS Nursing Home Salary & Benefits Report.

Every strategy ‘known to man’

As of this writing, National Healthcare Associates had no openings in its DON or assistant DON ranks, but the perception that wages are stagnant makes it that much tougher to hire when there is a vacancy, Scarpino added. Strategies to retain rather than replace get high priority at NHA.

“I can tell you that we have thought of every bonus incentive, either motivational or retention activity, that is known to man,” Scarpino said. “I think the only time that I’ve seen it more competitive is not necessarily during [the first wave of] COVID, but right after, as we were all trying to open at the same time, we were all trying to return to business.”

Although many providers are focused on competing for staff with agencies, travel nurse firms and other local healthcare entities, Silletto says there is a new foe they may not even take into consideration. That’s a massive increase in healthcare pay transparency, thanks to social media, publicly available surveys and websites, and even new legal requirements for job postings in some states.

“People talk more today about how much money they make than ever before,” she said, also quoting the adage that says, “Comparison is the thief of joy.”

Crazy comparisons

Comparisons between DONs and admins may be driving one significant split identified in the McKnight’s survey: Nearly 23% of DONs said they were “not so well paid” or “not at all well paid,” compared to 14% of administrators.

“It never surprises me that a second-in-command is less thrilled with their pay than the top paid person at any organization,” Silletto added. “A lot of people just think, ‘I should be paid just as much as the next person,’ if they see themselves in a more collaborative role.

“I honestly think there is nothing companies can do — outside of actually paying more — that can overcome this frustration people find,” she said. “When they learn how much money other people make, it is human nature to feel frustrated or jealous or angry.”

Another key finding, however, shows the disconnect between pay satisfaction and meaningful work. For the second year in a row, about 73% of respondents said they found their work “very meaningful.” Among administrators, that share inched up to 75.8%, while 68.7% of DONs reported their work was “very meaningful.”

Workers aren’t bending on flexibility

More nursing home employees also are insisting on flexible scheduling, following years of COVID conditions that have often called on them to work back-to-back shifts and take on overtime they didn’t necessarily want. Survey respondents indicated that not being able to offer flexible work is a major hiring and retention issue in a new economy shaped by the rise of the gig worker.

Overall, 40% of respondents told McKnight’s their workplace had made “some changes, but only for certain employees.” Another 35% said “some flexibility is now available for most employees.” That represents three-fourths (75%) of respondents, but some 13% said their facility or chain had made no effort “at all” to adopt more flexible scheduling.

“While accommodating flexible schedules can sometimes be a challenge for centers, providers need to change the way they have always done things,” said Kendra Nicastro, director of business development for healthcare recruitment firm LeaderStat. “If you are not adapting and developing new ways to attract candidates (flexible schedules, same or next-day pay options, etc.), you will continue to fall behind and recruitment and retention will continue to be a challenge.”

This was the first year that McKnight’s specifically asked whether employers were offering flexible scheduling. But in a separate question about potential changes that would most improve their job satisfaction, slightly more employees chose the option of a more flexible schedule in 2023 than in 2022, rising to 13.7% from 11.4%. Administrators were more likely than nurse leaders to choose that option at 14.6% vs. 12.3%.

Those numbers are likely far lower than if the survey had been offered to all nursing home staff, Silletto said.

“DONs and administrators have the most flexibility in the whole building. They can come and go whenever they want and if their kindergartner kid or grandkid has a two o’clock play, they can leave the building when most of their staff cannot,” she said.

Creativity emerges

That said, building operations are directly impacted by approaches that try to meet the desire for flexibility among other workers. Just under a quarter (24%) of survey respondents said their facility offered self-scheduling tools for employees; 46% had increased part-time opportunities, and 29% offered three- and four-day workweeks.

More than one-third of respondents (161) also entered an answer in “other” options that showed, for the most part, a willingness to explore flexibility. Those included the use of 12-hour shifts; PRN schedules or internal float pool; staggered shifts to accommodate school start times and other personal needs; and shift sharing.

Several respondents also noted in terse terms that their owner or corporate leadership refused to be more flexible with scheduling, or that union contracts prevented facilities from offering some options their peers had found success with.

“Most companies, honestly, haven’t had the bandwidth to explore more flexibility options,” Silletto said. “The way they’ve always scheduled, they know it’s not working, and yet, they don’t know what else to do.”

Middle ground elusive

Piperata said the leadership candidates she works with are “very much” demanding some flexibility, even if it’s just one day a week at home to catch up on all reports, emails and other non-clinical requirements. But she doesn’t see her clients, meaning nursing home HR leaders, budging much.

“When you’re leading the whole building either on the clinical or ops side, it’s the customer who wants to see you, it’s the customer who is wanting that visibility and that representation. So I get where the client is coming from on that,” said Piperata. “But I also get that we’re in this gig worker mentality. People want the flexibility to be able to have a day to get everything done or to work for longer days because staff nurses are able to do Baylor [12-hour weekend] shifts and things that do allow flexibility. So I think we’re just seeing the DON and administrator saying, ‘I want that, too.’ ”

Ted LeNeave, CEO and founder of Accura Healthcare, operates 34 skilled nursing facilities in the Midwest. While he’s hearing more requests for flexible and remote work options, he sees some positions for which that’s just not aligned with the business of doing healthcare. For instance, he recently determined a DON asking to work four days a week in the building wasn’t a “good culture fit.”

“It’s not that kind of job,” he said. “We can have flexibility in other areas, but we can’t have flexibility to not be in the facility if your job is in the facility taking care of those people.”

Scarpino takes a different view. He sees trying to be more amenable to employee desires as a way to avoid costly attrition.

“We don’t see as many people leaving the industry as we see people changing roles for additional pay, a better shift, more flexibility, a better commute,” he said. “I think the whole industry, not just senior living but healthcare in general, is really struggling with this idea of flexibility, particularly with so much attention being given to work from home outside of the industry.”

He’s exploring adding self-scheduling technology, seeing that as one of the best possible solutions. In the meantime, he’s trying to manage candidates — from leaders to brand new CNAs — who ask for special arrangements.

“We just try to be flexible with them as far as we can within the confounds of our operation,” he said. “Whether it’s a 16-hour shift, no weekends, only weekends, days, nights, evenings, those different things. There’s all kinds of different scenarios that we try to piece together to accommodate.”

Seeking solutions

Silletto applauds such flexibility and is encouraging hiring managers to think of their staff more as members of separate pods. One might be PRN and one might be part-timers; and another could be full-time, traditional eight-hour shift workers who never ask for accommodations. The employer can then pay incentives to each pod to ensure round-the-clock coverage.

“I would say an overarching theme — and employers hate to hear this, but it is a current problem — is fewer people in the workforce want to be told where to be when,” she said. “Offering as much flexibility and as many shift options and start and end times as possible helps it fit into their lives. A lot of people are less tolerant today of sacrificing for work.”

For leaders resistant to demands for flexibility, Piperata suggests testing it first in buildings where there might be less risk.

“If you have a 5-star building that’s performing well and the administrator and DON have been there a while, there hasn’t been a lot of turnover, why not allow something like that?” she asked. “I think that maybe they could start to look at it more from a custom standpoint. If your building is doing well, then you can earn this. If these two or three things are met, then this is something that we would work with you on versus just saying, across the board, ‘We’re not doing that.’

Without more change, recruiting nurses who can find the hours they want in hospitals and keeping entry-level employees who have plenty of options in retail or hospitality will continue to be a slog, Piperata said.

Reluctant providers need to think about how their stance positions them in what will only become a more competitive landscape in the coming years, Nicastro added.

“When candidates see flexible scheduling in a job description,” she said, “they can assume that your building is proactively addressing employee requests for work/life balance and working to stem burnout.”

Alarmingly, the U.S. Census Bureau’s Current Population Survey in 2021 identified of the 13.7 million workers displaced, 4.6 million direct care workers did not reenter the workplace, and 89% of them are not looking to come back to this industry. 

There is a multitude of reasons before, during and post-pandemic why retention of direct care workers has been difficult. Most workers are women who have limited post-high school education, carry the burden of being a single parent, and do not earn a livable wage, so they may work more than one job. Equally important for those who have not returned is that the daily work of providing direct care to older adults is physically and emotionally taxing. 

Current efforts are laudable yet fall short. For example, on April 26, 2023, the U.S. Senate reintroduced S. 2344 titled, Supporting Our Direct Care Workforce and Family Caregivers Act.  While the bill would direct the Department of Health and Human Services to award grants with a focus on building, retaining, and otherwise promoting better career advancements, we do not know if and when it would become law.  Even with increased paychecks, the physical and emotional burdens will still exist in their work. 

There are ways to support the physical and emotional burdens of care in the very short term. The National Council on Aging policies are grounded on the belief that disseminating the expertise of those who are often invisible and whose voices are not shared can improve the overall quality of life for all. Making visible how direct care workers became experts at what they do is a solution to recruitment and especially retention within this workforce and can create an overall healthy work environment. 

Telling their stories brings front and center the contextual foci that created the successful, caring relationship between carer and older person. Sharing the context highlights the problem-solving skills that created the expertise of the direct care workers. There is emerging evidence that deliberate storytelling, here to inform peers on successful strategies in caring for older persons, can inform future recruitment and retention activities. 

Many industries are using storytelling to train new employees, including creating short vignettes about the daily work and work environment. While success stories are uplifting, what has been demonstrated to be more impactful is sharing how the struggles of the work turn into solutions. In turn, the stories may dash a sense of burden or failure and support innovation and an environment to continue growing professionally. 

Identifying direct care workers as experts in caring for older people immediately empowers them. Working with these local experts to curate their stories into small, focused vignettes can energize the individual and those hearing or reading the stories. Sharing their stories in face-to-face sessions or digitally on websites can not only increase competencies in caring for older people but also ultimately can prevent or lessen burnout. Retention of care providers in the home or other community settings is a critical aspect of ensuring quality care and keeping costs of care in check.

Robin Toft Klar, DNSc, RN, FAAN, is a clinical associate professor at NYU Rory Meyers College of Nursing whose work focuses on the environmental context of nursing and the nursing workforce locally and globally. NYU Rory Meyers College of Nursing is home to the Hartford Institute for Geriatric Nursing.  

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.

It’s no secret that finding and keeping long-term care employees has become a bit of a challenge.

Nor are the numerous reasons for this unfortunate reality much of a mystery. After all, we’re just now getting to the tail end of a devastating pandemic. But setting COVID-19 carnage aside, the work can be hard, unforgiving and seemingly never ending. Nor are the pay and perks creating a new generation of deca-millionaires.

Can we agree that song sucks? But maybe, just maybe, it’s time to find a happier tune.

It’s funny, but whenever I ask people in this field what really motivates them to work hard and stick around, I never hear about the salary. Or the bennies.

But almost to a man or a woman, I do hear this answer (or something along the same lines): I get to make a difference.

As any coach will tell you, it’s important to play to one’s strengths. And all too often, employers in the skilled care sector fail to capitalize on what a powerful advantage that can be.

For context, when was the last time a shelf stacker at Costco, a burger flipper at McDonald’s or a product puller at Amazon proudly made that statement? My guess is that the next time will be the first.

Ladies and gentlemen, what we have in long-term care is a sure fire blueprint for recruitment and retention success: Simply emphasize the heartwarming and purpose-filling satisfaction that making a difference can deliver.

Have you heard of Simon Sinek? He is a leadership expert and author of multiple best-sellers including “Start with Why.” Here’s one of my favorite lines from that book:

“People don’t buy what you do; they buy why you do it. And what you do simply proves what you believe.”

While that statement might appear to target businesses that sell things, I think it’s just as applicable to service providers.

You know why you are in long-term care. But are you sharing that message with prospects, colleagues, subordinates and others? If not, you are passing up a golden opportunity.

Play that card, and the lousy hand you’ve been dealt just might be a winner.

John O’Connor is editorial director for McKnight’s.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.

More than ever before, providers must personalize scheduling and build programs that speak to individual employees to attract the next generation of workers, skilled nursing and senior living leaders emphasized during an expert panel discussion.

In addition, showcasing the sector’s possibilities earlier and doing so with a broader audience will also be key. Otherwise, demographic shifts threaten to leave nursing homes and other settings short on staff just as demand from baby boomers increases.

“We’ve got to develop more workforce strategy programs. Not every kid has to go to college. Kids need to come into this pathway. This is a phenomenal pathway for a solid middle class existence,” said Dan Reingold, CEO and president of RiverSpring Living in the Bronx, NY, at an early McKnight’s Pinnacle Awards gathering last week. 

“We’ve got to get to sophomores in high school and show them there’s a career path here and get them in a mentoring program. This is what we’re doing on our campus, but we think it has to go nationwide.”

​Reingold was one of six speakers invited to take part in the special roundtable last week. He was joined by  Chris Belford, CEO of Sinceri Senior Living; Lynne Katzmann, CEO and founder of Juniper Communities; Gary Nipper, director of business development for HealthDirect Pharmacy Services; Carl Tabor, president of Avamere; and Ben Unkle, CEO and president of Westminster-Canterbury on Chesapeake Bay. McKnight’s Long-Term Care News Executive Editor James M. Berklan moderated.

Power to the worker

Almost all of the speakers said they were giving employees more say in setting their own schedules. Katzmann said that approach was a natural extension of providing person-centered care, only shifting the focus to caring for employees (whom she calls “associates”) and their lives beyond work.

“They need to be seen as people. It’s not just about a certificate program for moving up. It’s understanding what they want as a human being, as an individual, as a professional,’ Katzmann said, noting Juniper’s recent efforts to roll out “individualized development programs” for more workers as part of a broader human capital program. 

She said her organization and others have leaned into a sales-based approach to recruitment, something they first dabbled with during the early days of COVID-19.

Sinceri Senior Living has also shifted to a marketing approach, hiring recruiters for a number of its 81 buildings, with most of the cost going to corporate. The facilities benefit from more staffing lead generation.

Belford also said Sinceri, which focuses on assisted living and memory care, reduced its agency use by 70% between 2021 and 2022. Much of that was due to a new outlook on scheduling.

“It’s just going to the employees as if they were residents and asking them, ‘What is your need?’ Some employees like four-hour shifts, some like six-hour shifts and some can only work Tuesday, Thursday and Friday because they have daycare then or they have another job,” Belford said. “So we opened up the gamut so they can kind of pick the hours they want to work and we fill the holes as we need to.”

He added that the thinking reflects that of Forbes 100 companies that are starting to entertain four-day day work weeks. He sees no additional costs, and said flex scheduling can reduce overtime and call-outs for illness or other reasons.

Unkle, whose continuing care retirement community has never used agency throughout the pandemic, said others should embrace the idea of marketing jobs in a better light. Like Reingold, he says it’s important to get an early foothold in a market’s talent pool.

“The high school and vo-tech schools are really critical, the tracks that are not college-based,” he said, adding that finding people includes using recently developed technology for targeting ads. “And if you’re geofencing for selling apartments, why aren’t you geofencing for selling your jobs? You’ve got to get off the fence a little bit.”

Among the staffing initiatives the speakers have employed are:

• Scheduling 4- and 6-hour shifts, and allowing workers to come in fewer days a week.
• Creating partnerships with community colleges on specific programs that can help make career ladders more realistic
• Using better technology to improve efficiency and reduce frustration among frontline workers
• Paying former employees who are in nursing school to complete their clinical rotations in their former facilities

Tabor, whose Avamere Living facilities specialize in post-acute, high-needs care, has more clinical demands than many of the other speakers. Keeping CNAs and nurses has remained a challenge for nursing homes across the US.

A former CNA himself, Tabor said his company has made an effort to elevate the role of CNA for those who want to remain in that position. 

“It’s great to move people along, but when you look at it statistically, maybe 10% of those individuals want to go on in nursing,” he said. “We implemented a recruitment and retention program through a vendor technology and we drove our turnover rate in six months from 70 to 50 [percent]. But more importantly, our 90-day turnover rate was less than 8%. Putting effort into retention and engagement programs is the solution.”

Immigration also needed

Several participants also beseeched the government to do more to address demographic demands that cannot be met by a US population that has too few working-aged people to care for its aging population.

“The immigration issue is something we really need to focus on,” said Reingold, noting that New York City sees some 40,000 new people arrive every three months.

“Give these people work permits while we figure it out. They’d help us tremendously. They’re not going anywhere. Let’s embrace them.”

“Long-term it’s the only solution with the demographics,” Unkle said.

Katzmann cited a recently published study by Harvard’s David Graboswki and others that found increases in the immigrant population result in improved nursing home direct care staffing levels, particularly among full-time staff, with little impact on industry wages or the skill mix. 

“They looked at whether the individuals taking these jobs essentially created a problem for other people who might want those jobs,” Katzmann said. “The answer was no, the quality was high and it solved a lot of problems.”

The hard truth is that too many companies just do not offer set career paths, and too many associates do not have the funds or time to invest in further education. In an environment historically replete with high turnover, new associates often don’t have mentors or role models to show them how to thrive in a facility.   

This kind of career stagnation, coupled with the difficult nature of caring for the elderly, is one of the primary driving forces behind the high turnover rates in skilled nursing facilities and assisted living communities. But the inverse is also true — employees are more likely to stay at workplaces where they can envision a future and find role models who care about their success in the organization.  If you’re looking to boost retention at your senior care facility, you need to start by focusing on creating career paths for your employees. Let’s dig in. 

Retention in senior care: The problem

Retaining workers in long-term care facilities is a challenge, period. According to a 2021 study published in Health Affairs, workers in nursing homes turn over at a median rate of 94%. Average turnover rates exceed 100% for registered nurses, certified nursing assistants and licensed practical nurses. 

These high turnover rates impact your quality of care, staff morale and the ever-increasing cost of hiring. These factors were only exacerbated by the level of trauma that the COVID-19 pandemic inflicted on the workplace.  

Additionally, as you are acutely aware, this constant turnover can rob residents and patients of stability and consistent care. And while there’s no simple solution to improving retention in long-term care, creating clear and defined career paths can help your employees envision a future at your company. 

You may not know that employees name “lack of opportunity for advancement or growth” as one of the top five stressors in the workplace. Even more concerning, for every 10 months an employee remains in the same role without advancement, it becomes 1% more likely that they’ll depart the company for their next role. It’s clear that lack of career growth is contributing, at least in part, to the high turnover seen throughout long-term care. 

But creating career paths isn’t always simple — some employees may not have the time or funding to pursue further education and move forward in their careers. Others may not be fully aware of the possibilities within their role. It’s your job to show employees that a bright future is possible without ever leaving senior care.  Here are some of the best strategies to employ. 

Two strategies for building career paths in your facility

1. Education reimbursements

Offer your employees a stipend or reimbursement for educational expenses. In healthcare, employees often need a new set of skills to move forward to positions with more expansive responsibilities and higher salaries. With education reimbursements, employees will be able to acquire the necessary skills without putting unrealistic stress on their budgets.

Tuition reimbursement is an excellent way to retain workers in all healthcare positions, but can be particularly helpful for CNAs. 

CNAs often face low pay and hard work. Even when wages are increased, it’s not always a guarantee for retention. That’s because there’s more than salary at play: CNAs need to feel valued and have clear career pathways to remain in their roles. 

In order to move forward to higher wages, CNAs will likely need education and training that not everyone can afford. But in an ideal world, being a CNA should be an introduction to a long and fruitful career in caring for the elderly.   

Further training and education reimbursement can give CNAs the opportunity to move forward in healthcare. Not to mention, if your CNAs are able to pursue further nursing education while working at your facility, word will spread, and your reputation will grow. In addition to training and retaining existing employees, you’ll also attract new candidates looking for a start in the medical field. 

2. In-house training programs 

In-house training programs, particularly for CNA certification, are always a great asset. CNA training can increase engagement from employees interested in learning new skills and potential candidates looking to break into the medical field. If you open your CNA training program to your non-clinical staff, you could offer these employees a path into healthcare and simultaneously add CNAs to your workforce. 

These training programs can build valuable skills, even if they don’t end in a certification. You can employ outside trainers to train your employees in everything from soft skills (such as customer service and patient interaction) to hard skills that employees will use every day. 

When you offer in-house training, you can also help interested non-clinical employees (such as janitorial staff, housekeepers, chefs and administrators) make the jump to the clinical side of things. Non-clinical workers are an important part of any long-term care facility, and some may be interested in learning about clinical roles. But non-clinical workers often don’t see a way to move over to the healthcare side of the operation, even if they’re very interested. Taking the time to launch a reskilling initiative specifically for non-clinical workers. This can be a great way to fill the gaps in your clinical staffing while simultaneously boosting retention. 

Most of us have some personal experience of what it means to feel stuck in place at a job. But hopefully, you also know what it feels like when a path opens up — to have the stability and excitement of clear goals and a way forward. This is what every employee in long-term care deserves and, ultimately, one critical part of preventing turnover. 

Pat Mulloy sits on the advisory board for Apploi, the leading software solution for healthcare recruiting, applicant tracking, and credential management. Mulloy is currently Of Counsel for Wyatt, Tarrant & Combs, chairman of the Board for Argentum, and formerly served as CEO of Elmcroft Senior Living and president and CEO of Atria Senior Living. Mulloy received his bachelor’s degree from Vanderbilt University and his juris doctorate from Vanderbilt University School of Law.

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.

Starting at 10 a.m. ET,  McKnight’s will offer five sessions on the issues that matter most to you: satisfying frontline workers’ demands and desires, assuring quality among staffing partners, building your own staffing pool, improving recruitment and reducing burnout.

This workforce development event is a must-attend event for anyone with employees. Period. The pandemic may have exacerbated the difficulties of fully staffing a long-term care, senior living or home care operation. But recruitment and retention will be ongoing challenges, no matter the time frame. 

In addition to recruitment and staffing experts, you’ll hear from peers who will share their own experiences and success stories. Come for one or stay for all of the following:

• 10:00 a.m.: Benefits: Are you missing what your frontline workers really want?
• 11:30 a.m.: Does your staffing agency care about quality assurance?
• 1:00 p.m.: Creating your own float pool using partnerships: A case study 
• 2:30 p.m.: Fighting back against staffing shortages
• 4:00 p.m.:  The untold secrets to optimizing your senior living and care workforce

Three of the five live workforce development sessions offer free continuing education credits. Please see the registration page for details. 

More details on each session and guest speakers can be found in the agenda.