With our aging population poised to create a nursing staff shortage, facilities will be wise to focus on nursing staff development and retention.

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t is no surprise that our population is aging. People 65 years of age and older represent the most rapidly growing segment of the United States population (see Figure 1).¹ The elderly population is expected to more than double to 87 million persons by the year 2050. Longer life expectancies have also meant that the number of adults 85 years of age and older is also increasing significantly.

Figure 1

       For the long-term care industry, America’s aging population translates to increased numbers of older, frail elders with complex health problems and, most importantly, insufficient numbers of qualified healthcare providers to care for them across the continuum of long-term care, including nursing homes, assisted living communities, and home care agencies.
       In its most recent annual report of nursing staff turnover in long-term care, the American Health Care Association reported an average turnover of nearly 50% for nurses and 71% for certified nurse assistants.² Several factors contribute to decreased job satisfaction and subsequent high rates of nursing staff turnover in long-term care, including:
• Poor relationships with supervisors and co-workers
• Lack of education and chance for promotion
• Lack of nursing staff inclusion in decision making
• Inadequate staff ratios
• Inadequate pay and benefits.
       The landmark report³ from the Panel on the Future of the Health Care Labor Force in a Graying Society asked the vital question, “Who will care for each of us?” Although nursing shortages have historically been cyclical and relatively short term, the nursing shortage we are facing will be very different. The panel’s report noted that “the 2010 shortages are systematic and attributable to fundamental demographic changes” impacting care recipients, healthcare providers, and family caregivers. Its recommendations focused on workforce development, team building, empowering nurses in decision making, and improving the public view of nursing care in long-term care settings as means to immediately begin addressing this looming crisis.
       This emergent demographic shift has significant implications for the long-term care industry. No longer can long-term care communities rely solely on workforce recruitment efforts; there just will not be enough “warm bodies” to fill the growing number of nurse and nurse assistant vacancies and new positions. Nurses and nurse assistants seek long-term care careers for the right reasons—they want to care for older adults, and many view their work more as a “calling” rather than merely as a job. Thus, the focus needs to be on nursing workforce retention from a new perspective. The focus must be on the fundamentals of retention: relationships, respect, and recognition.

Relationships, Respect, and Recognition

       Many long-term care communities pride themselves in the care and compassion provided to their residents. Yet, the public’s negative views about nursing home care are rampant in the media, and litigation cases against nursing homes for neglect or abuse are at an all-time high. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) identified root causes of sentinel events—which include falls, deaths, elopement, and suicide—in long-term care communities.⁴ Sixty-five percent of all sentinel events in long-term care between 1995 and 2002 were caused by poor communication. Inadequate staffing levels caused only 18% of them, bolstering the contention that recruitment alone is not the answer.
       In 2000, Mather LifeWays Institute on Aging (Evanston, Ill) and Life Services Network, the Illinois affiliate of the American Association of Homes and Services for the Aging (AAHSA), partnered to discover the fundamentals necessary to retain quality nurse leaders and frontline staff and to build a workforce initiative focused on both education and research.
       Initiating this process, the partners began by interviewing nurses, nurse assistants, and residents and asked them what was important to them in long-term care. The responses were all about relationships, respect, and recognition. Nurses said they want better communication, regard from co-workers, support from managers, and appreciation for quality work. Nurse assistants felt it was important that they are empowered with the ability to do what they do best—providing support, care, and affection to their residents. They also wanted to feel respected as key team members and have their skills valued by nurses. Finally, residents reported that it was important for the staff to know them as people, to be in relationships with staff to build trust, and to be cared for and spoken to as individuals rather than referred to individually as a caregiver’s “third bed bath of the day.”

LEAP: Learn, Empower, Achieve, Produce

       LEAP is a comprehensive long-term care nursing workforce program that aims to educate, empower, and retain nurse managers and frontline workers. The program challenges long-term care communities to rethink the vision and structure of their nursing workforce for nurses and for nurse assistants.
       The LEAP Modules (see Table 1) provide tools for nurses to creatively expand their roles through a professional practice model for nurses in long-term care and for certified nurse assistants to attain growth and promotion through career mobility paths.
       Common to both components are essential tools for nurses and nurse assistants to:
• Build positive relationships with residents, families, and co-workers
• Develop effective communication techniques
• Foster capable work teams
• Feel valued and effective.

Table 1

Taking the First Step

       Nearly 200 long-term care communities nationwide have taken the first step and participated in the LEAP “Train-the-Trainer Workshop” over the past 3 years. The Train-the-Trainer model has been demonstrated to be an effective way for organizations to prepare members of their own staff as educators who will bring back their knowledge and experiences to share with other employees, effecting stronger feelings of “buy-in” for successful implementation of staff development programs.
       Each community sends a team (minimum of a nurse manager and a staff educator) to a highly interactive 3-day Train-the-Trainer Workshop to be educated as “LEAP Specialists.” The LEAP Specialists are the vital links for implementing the LEAP program with their own nursing staff. As important components of the workshop, participants receive an expert review of their own teaching skills and a set of the 2 LEAP Modules that are self-contained with all tools needed to plan, implement, and evaluate the LEAP program in their own communities.

Taking the LEAP: Producing Measurable Outcomes

       Long-term care communities that implement LEAP can participate in annual evaluations conducted by Mather LifeWays Institute on Aging. Prior to implementing LEAP, participating communities complete an “Organizational Learning Readiness Survey” that focuses on assessment of 3 key areas: management style, readiness for learning, and capacity to implement and sustain LEAP. Administrators and nurse managers each complete a survey, and a report of results is provided along with recommendations on building a learning culture where managers and staff may embrace learning and development. Table 2 shows an example report with recommendations.

Table 2

       Program evaluation tools are included in the LEAP Modules and are administered by the community’s LEAP Specialist. All nurses and nurse assistants are asked to complete a brief survey prior to LEAP implementation and then after 6 months and 12 months of LEAP implementation. Key outcomes demonstrated to impact nursing staff retention and care quality make up the survey. These include job satisfaction, work empowerment, organizational climate, leadership behaviors, and work productivity. Reports of annual turnover rates, quality indicators, and health deficiencies are also compiled.

What Are We Learning?

       Nearly 40 communities have completed surveys 6 and 12 months after participating in LEAP, and their nursing staff members are reporting significantly improved job satisfaction, greater feelings of work empowerment, positive feelings about their organizations, and increased work effectiveness. Of value to the communities has been the ability to identify characteristics of effective nurse leaders through the program evaluation mechanisms. Nursing directors can use these criteria to screen qualified nurses who have greatest potential for retention and development.
       Resident and family satisfaction measures have also reflected these improvements. In the 2004 annual resident/family satisfaction survey conducted at Mather Pavilion, a skilled care nursing center, nearly 90% of family members were pleased with their inclusion in resident care. They reported that nursing staff kept the family better informed about resident care, responded promptly to questions, and were receptive to family ideas about care of their loved ones. Residents’ degree of confidence in skills of nurses and nurse assistants also increased since implementation of LEAP in this community.
       Keli Swales, administrator of San Joaquin Gardens (Fresno, Calif), a member of the American Baptist Homes of the West, provided some positive observations regarding LEAP’s impact on their staff and residents. Since initial LEAP training in October 2002, she has observed a greater “person-centered approach” to resident care, a 20% reduction in nursing staff turnover, and a more active role by their level 2 nurse assistants (promoted through the LEAP program) in quality improvement initiatives.
       Cindy DeGroot, nursing director at the Miller Center (Kankakee, Ill), described several ways LEAP has improved the quality of resident care in their setting. The team approach to care delivery focuses on prioritizing resident care issues resulting in positive outcomes for the residents. Nursing staff members feel more confident in sharing their observations about residents, and they have learned to provide positive reinforcement to each other when discussing resident care issues.
       Long-term care organizations that have additional resident quality improvement efforts underway have found LEAP to be a key enhancement to their existing programs. In an interview in AAHSA’s publication, Best Practices,⁵ Mary Ann Anichini, director of Project Excellence for 4 campuses of Presbyterian Homes north of Chicago, described her successes in using LEAP as the foundation for their organizations’ quality improvement programs. She noted that nursing staff learned to focus on their residents as a result of their LEAP program, rather than on the tasks of care.
       Nursing home quality measures⁶ are tracked for each participating long-term care community that provides care to Medicare-covered residents. For example, for the communities that implemented LEAP in 2002, nursing home quality measures for these nursing care centers have consistently been better than state averages in 2003 and 2004 in the following areas: percentage of residents with loss of ability in basic daily tasks; percentage of residents with pain; percentage of residents with restraints; and percentage of short-stay residents who are able to independently ambulate. Communities that implemented LEAP in 2001 and 2002 also saw an average decline of 38% in the number of health deficiencies in 2003 and 2004. This contrasts with their state averages, which showed increases of 71% during the same period.

LEAPing Forward

       Currently, the LEAP program targeting long-term care communities has received federal funding through the Division of Nursing, Health Resources and Services Administration, to:
• Expand the program to communities that have high proportions of Medicare and Medicaid-supported residents and to state Veterans’ homes
• Enhance the nurse components, including web-based continuing education courses and involvement of staff in quality improvement initiatives
• Evaluate the impact of the program on nursing staff retention, vacancy rates, and other key staff and resident measures.
       Additionally, a version of LEAP for senior living targeting interdisciplinary leadership for managers and team building in assisted living and independent senior living communities will be available in 2005.
       LEAP is part of a much larger initiative occurring within the field of long-term care, that of changing the culture toward person-centered, resident-directed, individualized care. The essence of culture change is about developing and sustaining relationships. LEAP lays the foundation to support learning and growth of the long-term care workforce while cultivating staff members’ relationships with residents, families, and co-workers. Staffing ratios and quality indicators will continue to be important benchmarks for quality, but it is far more likely that these essential relationships will have the greatest bearing on enriching the quality of work life for staff and the quality of life for residents.

Helpful Websites

National Clearinghouse on the Direct Care Workforce Practice Profile Database: http://www.directcareclearinghouse.org/practices
Better Jobs, Better Care: http://www.bjbc.org/page.asp?pgiD=14

For more information

For information on LEAP, a long-term care workforce development and retention program of Mather LifeWays Institute on Aging, visit http://www.matherlifeways.com/leap or call 847-492-6817.