Whether a provider operates a multi-site chain that is governed by a board of directors, is the sole proprietor of a single facility, or falls somewhere in the middle, turnover is a similar struggle for all.

Unfortunately, it is not just the turnover of direct care staff that plagues this profession—administrators and other managers churn as well. However, retention can be addressed in a thoughtful, systematic manner that yields greater commitment.

The Research

With such startling turnover rates, it is important to delve into why employees choose to stay and commit to long term care (LTC). A turnover rate of all nursing facility employees of 40.0 percent was reported by the American Health Care Association (AHCA) in the “Report of Findings 2009 Nursing Facility Staff Retention and Turnover Survey.” Their findings, “that America’s nursing facilities still experience high levels of turnover and relatively low retention for nursing facility employees, especially direct nursing care staff,” are consistent with what is reported in the literature (AHCA, 2011, p.4) The median turnover rate reported by AHCA in the “2012 Staffing Report” was 43.9 percent. Clearly, the problem persists.

Narratives, shared by 39 LTC employees with tenure ranging from 10 to 34 years, revealed why they have chosen to stay with Opis Management Resources and in the LTC profession.

Participants in this study consented to a single, individual interview. Stories were gathered about why employees have chosen to stay with a provider and in the profession.

The research included enough subjects to get a deep understanding of life in this LTC setting. Additionally, the research did not target specific positions. Rather, it examined the full range of employees in a facility, including nurses; certified nurse assistants (CNAs); and staff and management from dietary, laundry, maintenance, admissions, social services, and activities.
The sample represented a diverse cross-section of Opis employees. The 39 interviews provided a glimpse into the lives of employees tasked with the care of the people who are elderly and infirm. Of that sample, three employees were Asian, 17 African American, five Hispanic or Latino, and 14 Caucasian.

These participants came from skilled nursing centers throughout Florida; each of the company’s 10 facilities was represented. These people provided vital information about why they stay.

The Findings

The findings can best be explained by reviewing the key themes that emerged during the interviews. The single, overarching theme is that the organization inspires positive feelings. These positive feelings are woven throughout the interviews.

For example, a staff person in the dietary department told of being offered another position but opting to stay with the company because “I like this company better.” A CNA said that she is “very dedicated to” the company, and, as a result, “no other company can pull me away.”

This inspiration was reflected in an attachment to, identification with, and involvement in the organization. The impact of the company’s mission and the good feelings that exist toward the organization were clear throughout the interviews. It was also clearly reflected in the other three primary themes that drive commitment and retention: leadership behavior, a sense of connectedness, and opportunities for growth and recognition.

Lead By Example

Leadership behavior is a forceful driver of commitment and retention. Employees freely, often emotionally, cited examples of ways in which leaders throughout the organization have impacted their lives.

One such story was shared by a CNA, who detailed a practice that is commonplace in her facility. In her own words: “When your bosses come around and they know what section you work in, every morning they walk and they look and they tell you, ‘You know, your section looks good, you’re doin’ a good job,’ it motivates you to do a good job and try to do better. It means a lot to that staff member because you know that they recognize your work, and especially when they call you by your name. It makes a lot of difference when they call you by your name.”

While addressing an employee by her name may sound very basic, those who have been around awhile know that it is not a practice that is consistently or universally employed.

When examining leadership behavior, five clear categories of behavior emerged: leaders emphasizing learning, leaders focusing on employee needs, leaders making employees feel heard, leaders taking action, and leaders demonstrating charisma. Decisions made by leaders to model ethical standards and treat employees with respect were integral themes that ran throughout the interviews.

There Is No ‘I’ In Team

A sense of connectedness emerged as a central, driving factor in commitment and retention. Whether the connections are to managers, peers, or residents, the human connection is a profound and undeniable theme. The voices shared through the interviews told stories of relationships, bonds, and connections.
For example, a director summed it up when she said, “The atmosphere is like a family atmosphere, where everyone is respected and has a connection with the other one…people are concerned about if they don’t see you, they’re concerned about where you are, where you’ve been, what’s goin’ on with you.”

The fact that the organization offers opportunities for growth on many levels is another finding that was noted repeatedly. Multiple examples were offered, ranging from advanced training being important to CNAs, to the focus on leadership development for administrators, to the excitement of being offered the chance to try a new role for an admissions staff person.

A social worker said, “The company has helped me in so many ways, such as personal and professional development. I have always been given the opportunity to participate in different committees. I have had input in making decisions and then seeing them come to life. They just give you so much opportunity.”
These opportunities contributed to the sense of satisfaction, to commitment, and to staying in the employ of the organization.

The Implications

There are three clear implications from the findings of this research. The first is that human capital utilization needs to be an intentional focus by long term care leadership. How talent is acquired and managed needs to rise to the top of the priority list for companies interested in retaining, engaging, and earning the commitment of their employees.

It is important for LTC organizations to create a culture and climate that people actually enjoy and with which they want to be involved. Not only will this create mutual goodwill between the employee and employer, it will also change the dynamics between workers and residents.

While it is easy to pay lip service to valuing human capital, this research makes it clear that skillful human capital utilization requires a clear, compelling strategy. That strategy should include attention to creating an organizational culture and a climate that generates goodwill. It should also focus on a clear strategy for developing talent at all levels of the organization.

While education and training are components of talent development, there are other elements that should be considered. They include creating multiple methods of engagement, ranging from committees and task forces to external community service.

Commitment Goes Both Ways

The second implication from this research is the reciprocal nature of commitment. Employers expend tremendous energy and resources looking for ways to build commitment while overlooking the most basic. Employees are committed to employers who are committed to them.
A director summed it up in the most basic terms when she said, “I have a commitment to the company because I feel like the company has a commitment to me.”
Employers can measure their degree of commitment to employees by thoroughly analyzing their policies and procedures from the employee’s perspective. Cumbersome, antiquated policies and practices do not signal commitment to the employee.

Making The Mission Personal

While the literature on organizational commitment suggests that identification with corporate goals drives commitment, this research suggests something slightly different. The third implication of this research entails identification with the corporate mission. Crafting a meaningful mission and integrating it into the culture of the organization served the organization in this study well.
Employees from all levels and functions mentioned the mission and its impact on their work.  Employees repeatedly identified the corporate mission as an important part of how they conduct the business of elder care.
The question of why employees stay has been answered. They stay because they approve of the way that they are treated by leaders and peers. They stay because they have opportunities to learn, grow personally and professionally, and advance, should they choose.
They stay because the environment is characterized by positive emotions and positive experiences. They stay because of deep attachments to each other and to their charges. They stay because they are recognized for the effort they exert on behalf of people who cannot help themselves.
They stay because they are valued.
Joanne L. Smikle, PhD, provides consulting and leadership development to long term care organizations. She partners with clients to create organizations where retention, commitment, and engagement are the norm. Smikle can be reached at info@smiklespeaks.com or (301) 596-3140.