As the economy continues to improve and more job opportunities open up, it is harder to replace staff who leave. Maintaining current staff is all the more important.
Staff stability is necessary to succeed in this performance business environment. Health care payers and partners are increasingly focused on outcomes. Staff who work with the same residents and co-workers everyday can prevent avoidable declines. They recognize immediately when something’s wrong and can work together to address it.
It’s a common myth that staff will leave for a small difference in pay. When staff are part of a team and their contribution is valued, they aren’t inclined to look around. But if staff don’t feel their contribution matters, they will look for a workplace where it does. A few cents more is only tempting if the current workplace is stressful and unrewarding.
Company leadership and that of direct supervisors are the crucial ingredients to keep current staff. They will stay, even as options open up in a good economy, when they have a good daily work experience.
Just as the company can keep new employees by establishing a solid relationship from the start (see Part One, Steps 1 through 5, January 2016), so too, can it keep its longer-term staff by maintaining that relationship.
Part Two of this series encourages companies to create a stable environment, maintain a level of communication staff can count on, and put systems in place so staff can work together. With staff actively engaged day-to-day, the company will be well on its way to accomplishing the rest of its organizational priorities. Without staff stability and engagement, it will be hard pressed to succeed on any front.

STEP 6. Reduce stress and improve morale.

Today’s stressed-out employees are tomorrow’s call-offs. To reduce the stress:
■ Check in with people. Round daily and ask if staff have what they need, what they need help with, and how the new person is working out. Say thank you. Show a genuine interest in their well-being, both on and off the job.

■ Take management stand-up to the staff. A quick daily stand-up with staff allows leaders to check in and problem-solve on the spot with the whole team present so that communication is seamless. Leaders can use the stand-up to review a watch list of residents known to be especially vulnerable to decline, and they can hear from the staff immediately about any concerns.

■ Over-communicate. In the absence of direct communication from leaders, staff will fill in with their own assumptions and even rumors. Make sure they hear from leaders—and leaders hear from them—directly and regularly. Hold staff meetings to let staff know that management is working hard to bring good people on board, and invite them to be partners in the process. Keep them informed throughout the process.

■ All Hands on Deck. At the high-labor times of day, especially mealtimes, have the management team get out on the units and provide extra support. There are many nonclinical ways to help so that certified nurse assistants (CNAs) and nurses are available to attend to the services only they can provide.

■ Focus on morale boosters that build community. Have fun. Have cookouts and family events. Celebrate any successes. Show appreciation.

STEP 7. Create daily stability.

Aim for a perfectly staffed day:
■ No call-outs and no sick-pay hours.

■ No registry hours.

■ No light-duty assignments.

■ No orientation hours.

■ Fully staffed to budget—every shift, every neighborhood.

■ Total hours (not ppd).

■ Overtime = less than 1 percent (or four overtime hours).
Pay attention to attendance. It’s an area that tends to slip out of control during times of stress and can prevent management from getting traction to stabilize. While some absences are part of the vicious cycle as staff who are over-extended call-off, as the company makes more good hires and fills vacancies, staff stress will abate. This will allow managers to re-establish good attendance, which is necessary for continuity of daily care. Here’s how to get a hold of it:

■ Tell everyone daily stability is the priority. When everyone on the schedule comes to work, everyone can do their job and help each other out. Explain that management will be keeping track and talking with anyone who is struggling with their attendance. Remind everyone of the attendance policies that are in force and the help that is available.

■ Count it. Accurately track individual absences and look for trends. Assign one staff member to record all call-offs on individual staff member attendance records. Start tracking the total number of call-offs per month (whole staff, all call-offs count).

■ Let people know management is paying attention. Show staff how they are performing by sharing their attendance record with them each quarter. One director of nursing (DON) keeps a list on the white board in her office of everyone who calls off for the month. She says staff are startled to see their names up there when they stop by her candy bowl.

■ Discuss absences at daily stand-up, and act on them immediately. When people call off, talk with them within 24 hours and let them know they were missed. Assume that everyone tells the truth and that they all want to work as scheduled. When people are held accountable in a nice way with immediate feedback, they tend to want to do better because they know the manager will notice.

■ Have people call the administrator or DON. If the company has high numbers of call-offs, require anyone calling off to speak directly with the administrator or DON. This will eliminate frivolous call-offs and give leaders direct knowledge of and communication with staff who are struggling.

■ Be proactive. If someone has a sick child or is ill themselves, check in to see if they think they will be absent for more than one shift. The staff member who is most likely to call off tomorrow called off today. So plan ahead to get a substitute instead of waiting until they call off later that night.

■ Don’t use the attendance policy enforcement to substitute for holding people to high performance levels. If some individuals are not doing their jobs, deal with their performance issues directly, not through their attendance.


Scheduling and attendance go hand in hand. Some keys to scheduling success include:
■ Allow staff to trade days, within guidelines, such as:
○ Person scheduled to work must notify supervisor and scheduler of who is taking their shift and what the traded schedule is.
○ No overtime without approval.

■ Honor requests for time off. If staff need time off, give it to them. In an environment where everyone is working well together, staff will cover for each other. Better to have a planned absence than an unscheduled one.

■ Increase full-time and decrease part-time. Aim for at least 75 percent of staff members to be full-time. The company should be its employees’ primary employer. Have their full focus. Full-time staff are able to follow up and maintain continuity in ways that part-time staff can’t, because they aren’t there.

Having lots of part-time people is a scheduling nightmare. With a high percentage of part-time staff, schedulers focus on getting people their hours. With a high percentage of full-time people, schedulers can focus on building regular schedules. With regular schedules, the same staff work with each other and build teamwork.

■ Organize the schedule to maximize stability. One example is the 4-on 2-off schedule. People get into a rhythm of working four days and having two days off. They can count on it. They get regular rest and can plan ahead. By contrast, the every-other-weekend-off schedule is more complicated. It means staff sometimes work long stretches without a break. Their days working and days off vary from week to week. This makes planning ahead more difficult. It’s often hard in theory for staff to give up every weekend off. But, in reality, many staff come to appreciate the regularity and the pace of a 4-on 2-off. (It can be modified so that staff have every third weekend off.)

■ Make a master schedule for staff. Get it out at least a month ahead. Keep it up to date and highly visible. Indicate staff’s assignment on the master schedule.

■ Have consistent work teams. Have staff work on the same unit. Don’t move people around. When people work regularly with each other, they develop ways of pitching in at each other’s heavier times (see Step 9 on consistent assignment). Working with the same residents and co-workers enables staff to anticipate and plan their work, instead of having to continually adapt to new, unfamiliar needs.

STEP 8. Charge nurse leadership.

The company’s charge nurses are the most important leaders in the organization because they are the leaders where care happens. The organization’s performance depends on the quality of teamwork and critical thinking among staff closest to the residents.

■ Communicate in-person daily. Bring the nurses together for a quick stand-up, or round, and meet with each of them. Discuss staffing, clinical, and operational issues. They will step up their leadership as they are called upon.
Have expectations of their leadership. Make sure they are engaged leaders and are responsible for the teamwork among their staff. Expect charge nurses to huddle with their staff and show them how if they need help.

■ Evaluate the nurses. Individually assess each of them. Look at their clinical skills, their interpersonal skills, their dependability, and their leadership. Identify strengths, opportunities for growth, and action management can take to support that growth.
○ Act to improve their leadership. Leadership skills are rarely taught in nursing school. For many new nurses, this is their first time to step into a leadership role. Many long-time nurses who have for years been able to be crusty “my way or the highway” nurses, now need to be required to pay attention to their impact on team cohesion and performance. Address this with them directly. Identify specific practices and skills, and make a plan to support their development.
○ Provide regular support to struggling nurses. Consider the charge nurses the “canary in the coal-mine”—their stress is an early warning sign of a distressed workgroup and the poor outcomes that naturally follow. Use quick check-in meetings and regular rounding to touch base, identify needs, and provide support. Provide daily support to new nurses over their first three to six months, guiding them to step into their leadership roles and manage their time and their team.

STEP 9. Create systems that support teamwork and high performance.

Processes that have a high return include Consistent Assignment, Shift Huddles, and Inclusion of Consistently Assigned CNAs in Care Planning.

By caring for the same people every day that they work, they have in-depth and timely knowledge and insight to share with the rest of the care team. They are able to do the little things that make a resident’s day, catch early warning signs immediately and help resolve issues, and be part of the discussion about the goals of care.

Not only do these practices improve outcomes for residents, they also improve staff satisfaction and retention. People tend to stay in jobs where they are needed and where what they do makes a difference.

Consistent Assignment

■ Why. When staff work with the same residents and the same staff they become a cohesive unit. A team. Co-workers cover for each other during breaks, they help each other out when two people are needed, and they work out their schedules if one needs time off.
○ Residents benefit by having people who know them provide them with intimate care. This way of working provides a high level of connection and affiliation for both the staff and residents. Staff who are consistently assigned become very tuned in to the residents they care for and are able to note subtle changes that may indicate an acute change in condition. Consistently assigned staff are very valuable team members. They have critical information that can make a real difference for a resident.

■ How. Start by grouping staff so that they work in the same area every day. Make assignments based on staff’s interests and abilities. Some staff work better with people with dementia and others with short-term rehab.
○ Be fair. Make sure there is an even distribution of the workload. Have staff discuss what is needed to take care of each resident and together determine fair assignments. Revisit as census, acuity, and staffing change.
○ Make the schedule assignment-centered. Instead of having the schedule be built by giving staff their hours, structure the schedule around the resident assignments. Have primary CNAs and consistent back-ups for each resident assignment.
○ Don’t move them. Even if unscheduled absences occur, don’t pull staff. Pulling staff to cover for absent staff disrupts two groups of residents instead of one. Use All Hands on Deck instead.
○ Listen to what staff tell you about residents. They have timely, accurate information about residents that is crucial to the facility’s ability to deliver good care. When management values their contribution, they become even more committed to doing a good job. When it doesn’t, managers may be putting them in the position of having to go against what they know, such as when they are told to go ahead and get the person up or give them a bath, when they know that’s not best for the person at that time.

Not being listened to makes some staff not want to be consistently assigned but instead be able to maintain emotional distance as they carry out the mandatory tasks.


■ Why. Quick daily start-of-shift huddles with CNAs and nursing staff help get everyone on the same page at the start of a shift. Mid-shift huddles help everyone stay on the same page, updating everyone on current information. These huddles give the consistently assigned CNA a place to share information, and a way to game plan with the other staff ways of working together when needed.

■ How. These huddles are five to 10 minutes long and review residents by exception. Talk about anyone on a watch list, any new residents, anything unusual or of concern, and any appointments or new developments.
Nurses fill in any medical factors, contributing to what CNAs are sharing, or requiring extra attentiveness. Problem-solve on the spot. Huddles require good facilitation to keep on time and on target and draw out everyone’s contribution.

Involving CNAs In Care Planning

■ Why. Including CNAs in care planning makes the care planning process come alive. The information they bring to the table is so real and relevant that it changes the quality of the meeting. Residents and family members feel the comfort of having them in the room, and the caregiver is an integral part of the process. Using this valuable information and having this structured way of capturing the information formalizes the connection and affiliation the company is nurturing.

■  How: First make sure the care plan meeting is functioning well, that everyone is on time, prepared, and uses the time for real problem solving. Prepare CNAs by explaining how the meeting works. Consider a role-play of a meeting. Communicate the care plan meeting schedule to CNAs each week, post it in the break room, and note it on their assignment sheet. Have them work with hall partners to cover while they are in the meeting.
Have CNAs focus their contribution on three key areas:
○ Activities of daily living—any change in the person’s ability to participate in care?
○ Mood and cognition—does the resident seem content? Agitated? More or less confused?
○ Dining—change in appetite? Change in the amount of assistance needed for dining?


STEP 10. Quality improvement (QI) closest to the resident: Grow and develop staff.

This includes daily problem-solving about residents as concerns come up, QI rounding for clinical areas of focus such as antipsychotics or pressure ulcers, incident-specific reviews such as post-fall, and Quality Insurance and Performance Improvement pilots for performance improvement projects.

In all these situations, as the consistently assigned CNAs bring forward concerns, be sure to seize teachable moments.
Follow up and close the loop, so that they know what is being done and how it is going and can share how it is going from their end.

Staff appreciate opportunities to grow in their abilities and knowledge about what is happening with residents. Being involved at this level is very meaningful to staff as they are able to make a contribution to residents’ well-being at a critical juncture. It reinforces how much they are valued and bolsters their own commitment to the organization.

Where Everyone Wins

Nursing care centers are facing a defining moment. Performance at the point of service matters more than ever before. Success depends on the company’s ability to maintain staff stability and to engage staff. And that’s just what staff are looking for—a positive work environment where they matter. It’s a win-win.
Cathie Brady and Barbara Frank are co-founders of B&F Consulting. Brady can be reached at or (860) 334-9379, and Frank can be contacted at or (617) 721-5385. David Farrell, LNHA, MSW, is vice president, subacute services, at Telecare Corp. in Alameda, Calif. He can be reached at or (510) 725-7409.