In addition to the increasing demand for workers, is a growing elderly population. Today more than 1.5 million individuals live in 17,300 nursing homes. And the nursing home population is projected to double in 25 years and triple in 35 years. (2) What poses to be a great business opportunity for nursing and elderly homes, could prove to be problematic, should things continue on the current course.

The Mass Exodus
The healthcare profession is facing some substantial recruitment and retention challenges. Enrollments at nursing schools have declined significantly. Fewer young people are entering the healthcare field, and the front-line workforce itself is aging. Furthermore, turnover rates are high, at more than 100% annually for nurse aides. A frightening thought considering that nursing aids comprise 85% of nursing staff and deliver 90% of hands-on care. (3)

Faced with low wages, low job control, limited benefits, along with high physical and emotional demands, becoming a front-line healthcare worker might not appear too appealing. Most nursing home jobs are typically "low-wage and low-skill." For example, in 1999, the average hourly wage for aides working in nursing homes was $8.29, compared to $9.22 for service workers and $15.29 for all workers. Along with service workers, nurse aides are less likely to have employer-provided health insurance or pension coverage. Added to this grim picture, nursing homes have one of the highest rates of workplace injury, 13 per 100 employees in 1999 compared to 8 per 100 employees in the construction industry. (4) Without many compelling reasons to stay, many leave the profession for better options.

A Two-Way Street
It would be easy to shift all the blame on nursing homes, but the reality is that they’re not completely at fault. They too, are faced with a difficult problem, with no easy solutions. After all, offering better benefits and more job control is often not plausible.

In many cases, front-line employees can’t afford the contributory health insurance if/when it’s offered. Additionally, many employers are stuck between a rock and a hard place when trying to disseminate more responsibility in the workplace. While it’s been shown that involving aides in care planning can decrease turnover, the great majority of people who do nursing aide, housekeeping, laundry, and food service work are there because their current skill level will not allow them to get anything better. (5) Many have a low sense of self-esteem, and would be terrified if management were to unexpectedly walk through the door with a major project. It’s not as easy as telling them to accept responsibility for the care giving system. Plain and simple, you have to help equip them with the tools and knowledge necessary to gain and maintain responsibility.

Getting Back on Track
It’s estimated that 67% of nursing home expenses are for staffing. Furthermore, a recent study placed the cost of recruiting and training alone at $4,000 per new certified nursing assistant. Attracting and retaining quality front-line healthcare professionals won’t be easy. But as the saying goes, “doing something is better than doing nothing at all.” Whatever action may work is worth trying because of the substantial direct and indirect costs of recruitment, selection, hiring temporary staff, and decrease in morale and productivity.

The remainder of this article will highlight the tips and strategies your organization can utilize to help reduce turnover and retain quality staff. It’s important to point out that this list is not meant to be inclusive, nor is it all or nothing. Perhaps focusing most of your attention on just one or two of the items below might be the best way to direct your efforts.

Tip # 1 Find Out How Much You’re Losing
Do you have any idea on how much your organization spends on recruiting and training new hires? A complete understanding of turnover’s financial consequences often serves as the eye opener a provider needs to fully commit to a retention program. Knowing the cost of your turnover also provides a benchmark for cost-benefit analysis, since a retention program, like any major problem-solving initiative, will cost money.

Tip # 2 Learn What Makes Them Tick
Focus on the characteristics that make for a successful healthcare professional—traits that include compassion, communication skills, ability to cope with death and dying, and ability to handle such unpleasant tasks as bathroom visits and resident hygiene. With this in mind, take some time to talk to your long time front-line employees (if applicable). If they’ve held the position for a considerable amount of time, they must be doing something right, and it’s safe to assume that they enjoy some aspects of the job—so pick their brains. Ask them what they like and dislike about the job. Tell them to describe the qualities they possess that make them successful. You can also take a look at hiring records to assess any behavior and/or personality traits that are characteristic of your current quality staff members.

Also, use this information in interviews for prospective employees. Instead of saying, “this job will require patience, especially when residents are irritable and not feeling well,” ask the prospect what skills they feel it will take to get the job done. This way the prospect doesn’t have the easy option of saying that he/she can be patient and caring, rather he/she will have to describe in their own words what they think will be required of them. This is a great method to discern if they’re capable, and more importantly worthy of long time employment.

Tip # 3 Consider Culture
Some nurse aides and front-line employees lack job preparation skills like commitment, conflict management, and problem solving skills, such as emergency planning for transportation or day care. Many front-line employees are minorities, often very religious, with their family ranking highest priority, the church second, a good time third, and work trailing in the fourth position. Many facilities are failing to address their culture. Ask your employees what they value most. It might be a good idea of administering an anonymous survey, in order to get more honest feedback. As much as possible, try to incorporate the values and priorities your quality staff holds dear. For example, maybe offering discounts to near-by, preferred daycare centers could be a way to help single parent employees out.

Tip # 4 Revisit Benefit and Compensation Options
The relationship of turnover to patient care is clear and well documented: higher turnover interrupts continuity of care and is associated with lower patient care outcomes.3 By driving down turnover, a living wage for long-term care workers would, by itself, significantly improve quality. In 1994 and 1995, many Massachusetts nursing homes began front-line staff at almost 50% higher than average wages (paying approximately $7.50/hr). These workers earned annual raises with seniority and benefit package had affordable co-payments ranging from 0 to 20% of premium costs. Sick leave and vacation benefits existed, education reimbursement policies were available to and used by workers. Turnover at these facilities was much lower than the annual average 100.4% for the industry, though still higher than in most industries at 30 to 40% on average. (6)

While increased compensation, by itself, will not guarantee committed employees, it will acknowledge and recognize those who have demonstrated the values of the organization.

Tip # 5 Train and Retain
Due to busy schedules, highly trained staff is often deprived of crucial information that front-line workers gather on a day-to-day basis. This knowledge includes how to lift and turn specific patients safely, how to cheer them, who has grandchildren, who prefers warm water for bathing, who needs glasses for what, and much more. In addition, information exchanges would be beneficial from both sides—the front-line workers would gain from understanding nursing decisions and why they are made. Cross-functional teams could be tied to training, mentoring, or upgrading opportunities for front-line staff, all of which are mainly absent in many homes.

Some segments in the industry suggest a complete transformation of front-line workers is in order, by developing a clear career path. Integrated Health Systems, a large care provider, decided to address retention with in their facility and make it their first priority. They addressed orientation, mentoring, career growth, recognition, supervision and compensation and realized a savings of $14 million during a nine-month period. (7)

Bottom line: If your organization pursues and follows through with a retention strategy, it will become clear that you’re offering people not merely a job but a career path. When this happens, you not only retain existing employees, but you attract the kind of people who are interested in making a long-term commitment.

(1)Scanlon, W. (2001) Nursing Workforce, Recruitment & Retention of Nurses and Nurse Aides Is a Growing Concern, Testimony, US General Accounting Office.

(2)Dick, A., Garber, A.M. and MaCurdy,T. (1992) “Forecasting Nursing Home Utilization of Elderly Americans.” National Bureau of Economic Research, Inc. Working Paper No. 4107.

(3)Harrington, C.A. (1996) “Nursing Facility Quality, Staffing, and Economic Issues.”

(4)Herzenberg, S. Alic, J. and Wial, H. (1998) New Rules for a New Economy: Achieving Postindustrial Prosperity. New York: Cornell University Press.

(5)Deutschman, M. “How to Attract and Keep the Best and the Brightest Workers in Nursing Homes,” Stride.

(6)Hoffman, R. (2001) “One Organization’s Solution to the Problem of Turnover” Nursing Home Magazine.

(7)Hunter, LW. (Forthcoming) “Building Employment Relationships: The Case of the Massachusetts Nursing Home Industry/” PhD dissertation, Massachusetts Institute of Technology, Sloan School of Management.