Denise Boudreau-ScottLong term and post-acute care (LT/PAC) providers in this country are already feeling the impact of a shortage of employees, and, according to statistics, the problem is going to get worse.According to Bureau of Labor Statistics estimates, the direct care workforce currently surpasses 3.5 million, and the projected demand calls for an additional 1.3 million new positions by 2022.
At the same time, the population that most often works in these positions, women age 25 to 50, is shrinking. Some centers in the country cannot bring new residents into their community because there are simply not enough staff to support them. If recruitment and retention efforts in the LT/PAC field are not ramped up, this will become a more common occurrence.
Another outcome of the staffing shortage is that providers often resort to hiring anyone who applies for the job, so long as they meet the minimum requirements for licensure and pass the background checks. While some of these people may end up being great team members, many of them do not perform at the level expected.
When staff leave, whether voluntarily or involuntarily, additional open positions are created. What will happen when the staffing crisis gets even worse, and what can be done about it? The answer is to hire more of the right people and to provide an environment in which staff are treated by leaders in a person-centered way. In many cases, in order to provide such an environment, a change in the culture of the organization is necessary so that team members feel appreciated, listened to, and respected.

Keeping the Right People

People who work in this field want to make a difference in residents’ lives. They want to feel supported by their supervisors to do the right things for residents. A study published in The Gerontologist found that, across settings, direct care workers said that what would most improve their jobs, in addition to increased pay, is better working relationships. This includes communication, appreciation, and being listened to and treated with respect by supervisors.

If employees do not get these elements of a positive work environment, they will leave their current employer. Perhaps they will stay in aging services and go to work across the street for the competition, or, as too often happens, they will enter an entirely different field, which contributes to the shortage issue.

Benefits of Person-Centered Care

Though it is often thought about as a resident-focused philosophy, person-centered care benefits the staff just as much as the people that they support. Simply put, person-centered care is a reason to get out of bed in the morning. Residents need a purpose and a reason to want to get up and live another day. Team members need a job that is meaningful so they are looking forward to getting out of bed, too. 

A first step to embracing person-centered care and improving the resident and staff experience is to ask those in the community, “How can things be better for you as a resident or team member here?” Are team members excited to come to work, or are they dragging themselves in the door? While most staff are not coming in skipping every day, they should be eager and proud to be there most days. It takes a willingness to ask and listen to the team and residents, to hear about what things go well so those bright spots can be replicated. It also helps to be open to hear what does not go so well so those areas can be addressed.
The Artifacts of Culture Change Tool, developed by the Centers for Medicare & Medicaid Services and available electronically from Pioneer Network at, is a great way to start. It is important that the tool not be completed by just the administrator and/or director of nursing, but a team, including residents. See for ideas about who to include and how to facilitate the discussion.

After completing the tool, celebrate what staff are already doing. Then, review areas that can be strengthened and create action teams to work on making the changes that will make things better for both residents and staff.

For administrators, focusing on improving the resident and staff experience can be a life-changing event. Most of those in the LT/PAC field know that there cannot be happy residents without happy employees. But what is also true is the better a care team is, the better off the administrator is in his or her job. When staff are empowered to make decisions on their own, the administrator can stop putting out fires all day long and focus on the larger projects that could make a significant difference in people’s lives.

The Case for Culture Change

According to research from The Commonwealth Fund, care centers that are further along on their culture change journey have fewer deficiencies, higher census, and higher revenue. The research also found that there were fewer incidents of pressure ulcers. 

Overall, what much of the research says is that it is challenging to measure culture change in hard data because there is so little baseline data, and what one person self-reports as culture change another might not. 

Beyond the hard data, how would a center measure a resident who previously attended activities as a bystander and now is the leader of a peer-to-peer group that supports fellow residents? As Einstein said, “Not everything that matters can be measured, and not everything that can be measured matters.” Rarely, if ever, does a leader who has focused on person-centered care say, “This doesn’t work, and we are going back to the old way of doing things.” 

Jim Collins, the author of the book “Good to Great,” talks about picking up the rock and seeing the squiggly things underneath. A leader can throw down the rock and pretend those squiggly things don’t exist or commit to taking care of them. If the company decides to commit to taking caring of them, the Pioneer Network website,, has some wonderful free resources, including the Artifacts of Culture Change Tool as well as many others, to help it do so.

Denise Boudreau-Scott is president of Drive: Outcomes through Culture, and a board member of the Pioneer Network. She can be reached at 732-722-8417 or