Across the country, nursing care centers are seeing an uptick in turnover. Many homes are having a hard time filling vacancies and are struggling to attract good candidates to hire.
This growing instability is compounded when new employees leave in the first weeks and months on the job. Remaining staff are stretched thin covering extra shifts, working short, experiencing declining morale, and wondering how long they can last.
This is a trend that needs to be taken seriously. The recovering economy is having a growing impact on long term care’s ability to maintain stable staffing. Today there are many options for people looking for work or to change jobs. Consider this staggering fact: In 2009, there were 6.7 unemployed people for every job opening, according to the Bureau of Labor Statistics. Today, there are 1.6 unemployed people for every job opening.
Long term care is entering a new phase in the cycle of staff instability. A good economy makes more job options available. The result is that dissatisfied staff can and do leave. They now have options. Once people start leaving, the vacancies they create become harder to fill in a tight labor market, and nursing centers can easily spiral into disastrous instability.

The Ties That Bind

Staff stability is the precondition for quality outcomes. Stability allows for staff to work consistently together with the same residents, so that they recognize early warning signs of changes in conditions and can act to prevent avoidable declines.

As government and private payers move aggressively toward rewarding value over volume and holding back payment for preventable adverse events, nursing care centers can ill afford to operate with high turnover rates, persistent vacancies, and corrosive unscheduled absences.

Susan Eaton, in her 2002 study, “What a Difference Management Makes!” mapped the vicious cycle of vacancies that lead to stress, absence, and turnover. (See graphic, above.)

Not only does this vicious cycle of instability siphon off limited financial resources, it makes it impossible to provide the continuity of care needed to prevent an avoidable hospitalization or understand how to soothe a resident’s distress without antipsychotic medications.

So what can long term care leaders do to break the emerging cycle of instability? The key is a comprehensive human resources strategy that resonates with the people drawn to caregiving. People work because they need a paycheck. But they also look for affiliation and connection from their work. Long term care jobs have the potential to be high in affiliation and are very attractive to people who want to make a difference in others’ lives.

By following the 10 steps highlighted in this two-part article, leaders are able to attract and retain employees who are intrinsically motivated to help others.

Part 1 (Steps 1–5) focuses on achieving staff stability through a hiring and welcoming process that establishes a positive connection from the first ad through the first six months for new employees.

Step 1. Look at the data.

■ Measure and benchmark the organization’s metrics against the local market. Use American Health Care Association or Advancing Excellence as the go-to websites to measure accurately. Set goals for each of these measures. Suggested goals: Turnover 20 percent; Retention 85 percent; Absences 25 per month in an 85-bed skilled nursing facility (SNF); Staff Satisfaction in top 10 percent.

■ Deep dive. If the facility measures high turnover rates in the first six months of employment, it will need to get granular with its measurement. How many are leaving during orientation? Within the first two weeks? The first month? The first three months?

■ Measure absences by person, unit, and shift. Look for patterns, repeaters, and trouble spots.

Step 2. Evaluate if the center can attract motivated, high performers.

■ Analyze. How do wages and benefits compare with other employers in the local market? Why do current employees stay on? Are they being lured with lucrative offers from competitors?

■ Ask current staff. Remember that word-of-mouth from the center’s employees is the most potent advertisement it has. Round daily, hold staff meetings, and ask the highest performers to help the company find more high performers.

Step 3. Improve the pool of candidates.

■ Make ads reflect what the center has to offer as a good place to work. Emphasize the caring teamwork and the opportunity to grow skills and to make more than a paycheck. (See sample ads on page 30.)

■ Create a sense of affiliation, starting with the ad. Use pictures of staff and quotes to convey the warmth of the workplace and the opportunities provided by working there.

■ Advertise for one specific job rather than so many that the company seems desperate.

■ Identify a person on staff that applicants can call. This may help attract high performers and dissuade low performers from applying. Oftentimes, a person can get a feel for someone and how they may perform simply by speaking to them on the phone.

■ Tap nursing schools. Don’t wait for graduation—company staff who have graduated from local schools, or who are currently students—to approach other current students.

■ Use refer-a-friend bonuses strategically. The best chance of hiring a high performer through this program is by paying the referral bonus to a current high-performing staff member who made the referral. This is a win-win-win because the company is telling the staff members how much they are valued, it is getting good people to recommend other good people, and it is hiring someone whom other staff will welcome because they are a co-worker’s friend.

■ Reach out to local papers. Events at the nursing center can serve as soft advertising (for example, Veterans Day; Memorial Day; staff appreciation, including celebrations of years of service, a resident’s 100th birthday—with quotes about how much “We’re like family.”). Many weekly community newspapers appreciate a good picture and story, and their coverage keeps the center in the minds of local job seekers.

■ Avoid using a sign-on bonus. This practice has more negatives than positives: 1.) It attracts people drawn to the money who may leave after the bonus is paid; 2.) It indicates desperation; and 3.) It makes current staff feel devalued.

Step 4. Improve the hiring process.

■ Make the receptionist the first screen. How applicants treat a receptionist is very telling. Make sure receptionists have postings, applications, and info on benefits and provide a warm welcome that attracts the people the center wants on its team.

■ Screen, tour, and interview walk-ins in order to hire high performers. If they pass the receptionist’s screening and the center has a vacant position, a hiring manager should be called on to conduct a tour with the applicant. The tour is the second level of a rigorous screening process. It’s during the tour that the applicant is assessed for social skills—eye contact, an easy conversation, a quick pace to their steps, a quick and genuine smile, and comfortable speaking with residents. Those that pass this screen should be interviewed right after the tour.

Include others in the interview process. Department heads, co-workers, and residents are important stakeholders to include. Make sure they know the legal rules about what they can and can’t do in an interview. This step establishes affiliation right from the interview process and provides a gateway for a better welcome when people take the job.

Hire for character. Use interview questions that get at the person’s character. Questions that are behavior- and scenario-based can help to identify if candidates are warm, friendly people.

■ Hire people who are looking for full-time and avoid hiring people who will only work as needed (PRN). Create full-time positions by combining part-time and PRN shifts. If the facility’s schedule is filled with part-time and PRN staff, the organization is set to struggle. The schedule will always be a patchwork, and so will the daily delivery of care. 

Step 5. Improve and extend the orientation and welcome.

Employers often think that they are the only ones doing the assessing and forget that the new employee is sizing up the center as their workplace. This means that the hirer needs to pay close attention to establishing a solid relationship throughout the hiring process—especially during the orientation and first few months.
To get a true picture of what it’s like to be new in the building, consider mapping the current orientation process. Look for how time is spent and on what. How much of the orientation time is spent actively engaged and connecting? How much is a check-off of forms and videos?

A Work Place Like No Other

Long term care is a work place like no other—it offers a family-like setting where people truly care about each other, opportunities for job advancement and growth, and a place where each staff member makes a difference.

Providers need to live up to their potential as a workplace, from their advertising through their on-boarding process. But remember that the best path to staff stability is keeping the good staff who are already there. Their day-to-day work environment creates the experience new staff join. Be very intentional when thinking about all of the ways to tap into the best in human nature by providing a work environment that lets staff know they are valued.
Cathie Brady ( and Barbara Frank ( are co-founders of B&F Consulting. David Farrell, LNHA, MSW, is vice president, subacute services, at Telecare Corp. in Alameda, Calif. He can be reached at