Long-Term Care Survey Alert

Pay isn't the only thing that matters.

High turnover and unfilled staff vacancy rates create a vicious downward spiral that leads to poor patient outcomes and unnecessary hospital admissions. Read on for advice on how to buck the trend from Mary Jane Koren, MD, MPh, vice president for long-term care quality improvement at the Commonwealth Fund.

"Research is really starting to demonstrate that there's a very close link between staff turnover and quality, and the higher the rate of that turnover . . . the higher the impact it has on quality, not just for nurse's aides, but also for the licensed nursing staff and administrators," Koren warned during the April 17 CMS webinar. That is why staff stability is one of the primary goals of the Commonwealth Fund's Advancing Excellence in America's Nursing Homes program.

There are a variety of reasons why staff leave nursing homes including, too many residents to care for, low pay, not being valued by the organization, dissatisfaction with the supervisor, lack of opportunity to advance, and the inability to provide quality care. "While everyone immediately says, 'Oh, the pay is too low,' in fact there are many other reasons that nursing assistants leave their jobs. If you talk to nurse's aides, they will tell you that they love the work but hate the job," Koren explained.

There is a myth that aides quit their jobs at nursing homes to work at fast food restaurants, but many times that is not the case. "Instead, they often go to other nursing homes, hoping to find the kind of conditions that will enable them to do the type of job that will meet their expectations for high quality," noted Koren. "In many nursing homes, there is no opportunity for them to advance, and they are very dissatisfied with the supervision that they receive, from both the LPNs and the RNs," she added

Domino effect: This lack of job satisfaction creates a vicious cycle of staff call-outs and turnover, which then leads to vacant shifts, which adds to the stress experienced by staff, which then leads to poor judgment, errors, injuries and bad patient outcomes. In addition, it becomes a huge financial burden to facilities, Koren added. "Many nursing homes spend $35,000 to $50,000 a month on agency staff, trying to fill vacant shifts. Also, working short means that there's a lot of resentment built up by staff, and they become very anxious, and this stress leads to errors in judgment, and it also leads to injuries," she warned.

Although most nursing home staff do deserve more pay, there are other, more effective ways to attract and keep workers, Koren advised. "What matters the most to employees is that the management cares about them. For example, some places will start a day care program so that the employees can bring their children there and know that they're being well taken care of," she noted.

Management should also really listen to staff and get them the things they need to do their jobs safely and correctly. "Certainly, the supervisor caring for them as a person is clearly important. Just having a supervisor who knows each person's name, and who says 'thank you,' when something is done well, is invaluable to keeping staff," Koren explained.

Once a facility is able to maintain a stable, content workforce, they can then consistently assign the same CNAs to care for a particular resident. If done correctly, this means that one resident will be cared for by only six to eight CNAs over the course of a month, Koren said. This allows CNAs to really get to know their residents, so that they are then able to detect and report changes in a resident's condition early enough to avoid a visit to the emergency department and a hospitalization.

Hidden benefit: This can be particularly important for residents with behavioral disorders, Koren noted.

"The cause behind many of these behaviors is often the inability of residents with severe and profound dementia to communicate with staff their needs. It may be that they're in pain. It may be that they're hungry. It may be that they need to use the toilet," she explained.

"What we find is that when you have consistent assignment, very often because the aide knows that resident really well, they can readily identify what the real problem behind the behavior is, because through a period of trial and error, they start to understand what these behaviors are communicating," Koren explained.

In addition to leading to better quality of care, research has shown that using consistent assignments 85 percent of the time results in fewer survey deficiencies, 41 percent fewer vacancies, and 31 percent less turnover, Koren noted. "If you talk to nurse's aides, one of the key factors for them that leads to job satisfaction is having a good relationship with their residents."

Consistent assignments also lead to greater resident satisfaction. "Think about this from a resident's perspective," Koren noted. "If you are elderly, have dementia, or memory problems having to deal with even six to eight people providing the most intimate care for you is really something that feels very dehumanizing. Residents say that the most important thing to them is the relationship that they have with their nurse's aide. So consistent assignment is a win-win on both sides."

Let CNAs decide: Koren suggested that facilities using consistent assignment allow the aides to decide among themselves which residents they are going to be working with. "If there are some residents who are particularly difficult, often the aides will agree among themselves, 'OK, you will have six residents to care for instead of eight.' But, again, we have found that when the nurse's aides really get to know the residents, usually the behaviors are much modulated and dropped off, because the aides pick up on what's really being communicated with a lot of these behaviors."

Editor's note: Free educational resources and tools for reducing staff turnover and improving nursing home performance improvement are available from the Advancing Excellence program at: www.nhqualitycampaign.org.