Health care

Health careDeveloping and retaining quality nurses and CNAs are crucial to the future of long-term care (LTC). Recruitment alone will not keep pace with the aging workforce, the rising acuity of nursing home residents, and the growing competition for the same pool of workers. A "care gap" is anticipated, with a smaller proportion of younger adults available to function as formal and informal caregivers to the growing number of older adults.

Unfortunately, this is not a "futurist" prediction. The Paraprofessional Healthcare Institute (PHI) reported that one million new CNAs will be needed by the end of the decade to fill LTC vacancies and new positions. (1) According to the Bureau of Labor Statistics, nearly 400,000 women will enter the U.S. workforce by 2010. (2) If all these women agreed to forego other careers to seek CNA positions, we would still be short 600,000 persons. There are similar projections for LTC nurses over the next 20 years.

Tackling the looming LTC workforce crisis requires the commitment and joint efforts of administrators, managers, and frontline nursing staff. Put another way, "it takes a village" to promote staff retention. Providing quality care on a daily basis to LTC residents is physically, mentally, and emotionally challenging. LTC organizations, therefore, need to focus on empowering frontline workers through educational opportunities, recognition, and resources that will better balance their work responsibilities.

Lessons Learned From Business and Industry

In extensive studies across a wide array of businesses, the Gallup Organization asked successful employees why they remained in their organizations and what motivated them to give their best efforts. (3) These employees consistently reported that positive relationships with their direct managers was the key determinant. Specifically, employees stated that their managers:

* cared about them as persons,

* consistently gave feedback on work performance,

* provided encouragement at appropriate times, and

* included them in decision making.

How different are the factors that support retention and productivity of LTC staff from those influencing employees across other businesses? According to the PHI, there are, in fact, many similarities. (4) In PHI's study of CNA retention in LTC settings, frontline workers who stayed in their positions reported that they:

* worked with fair-minded supervisors who showed interest in their lives,

* had education and career development opportunities,

* worked with nurses who valued their input,

* were made to feel part of the care team, and

* had adequate resources to provide quality care.

Interestingly, while clearly an important issue to all employees, CNAs in this study did not identify salary as a key retention factor.

The Three Rs of Retention

Most seeking careers in LTC do so for the right reasons--they enjoy working with older adults, the continuity of care allows them to get to know residents like family members, and they see their work as an important service to their communities. Once they enter the field, however, many are inadequately prepared to deal with management issues (i.e., delegation, giving constructive feedback, mentoring new employees, and team building) or with clinical issues (i.e., recognizing cognitive and physical changes in residents, communicating with family members, and coping with death and dying). Psychological and emotional demands quickly take their toll on staff (i.e., job stress and burnout, growing personal health problems, and chronic absenteeism), leading ultimately to turnover. This takes a further toll on the remaining staff, who must cover short staffing, work with outside agency nurses, and deal with residents who ask sadly, "Isn't Jeannie going to take care of me today?"

To build a quality LTC workforce that provides compassionate, skilled nursing care, we need to step back and look at the fundamentals, the three Rs of retention: relationships, respect, and recognition. These are important to all of us in our daily lives. It is no different in the lives of direct care workers, managers, residents, and families. But, as noted, it takes a village to promote a culture of caring and growth. Residents have told us what is important to them--they want the care staff to know them, to have relationships with staff, and to be treated as individuals. Nurses have told us what they need: better communication, supportive managers who back their decisions, appreciation for jobs well done, and respect from coworkers. CNAs have expressed their needs, too, i.e., being able to do what they do best in their jobs: providing affection, support, and care to their residents; working as team members; and having their knowledge and skills valued by nurses.

The foundation for retention--consisting of the three Rs--is clearly there. It is now time for LTC administration to build on that foundation. The following is the story of how one facility is doing just that.

LEAP: A Comprehensive LTC Workforce Initiative

The Mather Institute on Aging of Mather LifeWays, Evanston, Illinois, and Life Services Network, the Illinois affiliate of the American Association of Homes and Services for the Aging, collaborated to develop, implement, and evaluate LEAP*, a comprehensive ETC workforce initiative that aims to educate, empower, and retain staff through these components:

* A resident-centered approach to developing effective nursing leaders and frontline staff

* Interactive teaching methods based on adult-learning concepts

* Assessment of the LTC organization's learning capacity

* Evaluation of the LEAP program's impact

* A "Train-the-Trainer" course preparing staff to effect change in their own settings

LEAP trains and equips LTC frontline staff with skills that help them feel valued and effective, develop positive relationships with residents and families, sharpen assessment skills, build capable work teams, and release hidden talents.

The LEAP program consists of two modules. Each module engages participants in a variety of interactive experiences based on concepts from adult-learning theory, including experiential learning, use of audiovisual materials, hands-on demonstrations, and role playing. Lessons begin with introducing new knowledge ("Learning") for staff to employ in their work settings ("Empowering"). Lessons continue with individual and group activities in which participants develop action plans ("Achieving") that they are expected to implement ("Producing"). Module 1 is The Essential Roles of the Nurse in Long-Term Care Nursing. This module trains nursing managers and charge nurses to develop their roles as leaders, gerontological clinical experts, role models, and team builders, and focuses on the relationship between nurses and CNAs. Module 2 is Growing the Heart of Care: Career Development for CNAs, which includes skill development, a mentorship program for new CNAs, and a career ladder.

Since October 2002, 20 LTC organizations from Illinois, Wisconsin, California, and Georgia have sent more than 50 staff-development and human-resource personnel and DONs to four-day Train-the-Trainer workshops to become "LEAP specialists." Having returned to their organizations, nearly half are at various stages of LEAP implementation in their own settings. Trainees have found the sessions on person-centered care, communication, leadership, and teamwork particularly applicable to their daily work. Managers have told us about CNAs in their organization who have developed into effective mentors to new staff and who are taking initiatives to improve quality in a cost-effective manner.

In the end, retention is about developing and maintaining relationships, respecting one another, and recognizing quality work. LEAP endeavors to support the growth and development of nursing staff, while nurturing their relationships with residents, families, and each other. While staffing ratios and other measures will continue to be a benchmark for quality, it is far more likely that the three Rs will have the longest-lasting impact on improving the quality of LTC.

* LEAP is an acronym corresponding to the following objectives: learning to use tools and resources for quality LTC, empowering caring and competence in self and others, achieving commitment to work teams and the organization, and producing opportunities for growth and development.


(1.) Paraprofessional Healthcare Institute, North Carolina Department of Health and Human Services. Results of the 2002 national survey of state initiatives on the long-term care direct care workforce. Bronx, NY: Paraprofessional Healthcare Institute, 2002.

(2.) U.S. Bureau of Labor Statistics. 2001 Employment and Wages for Selected Health Care Occupations and Industries. Washington, D.C.: Bureau of Labor Statistics, Occupational and Employment Statistics.