Mary Tellis Nayak, RNIt’s an inevitable part of the job. No matter how nice their community, no matter how engaged and attentive their staff, every administrator in long term care will eventually have to field a complaint from a resident or a family member.

While nobody relishes hearing how they’ve disappointed someone, administrators should remember that complaints aren’t necessarily a bad thing. In fact, complaints can be some of the most important drivers for meaningful improvements within an organization—that is, if leaders are willing to approach them constructively.

A change in perspective can help. Instead of dreading to hear from upset residents and family members, administrators can learn to harness complaints as a force for good in their community. But this requires that they understand who’s really complaining and, more importantly, why they choose to do so.

And while uncovering these facts might seem simple enough, the data show that resident complaints are not as straightforward as they seem.

Just the Tip of the Iceberg

Start with the quantity of complaints. Administrators may already know that they’re unlikely to know about every gripe from residents and family members. There simply aren’t enough hours in their day to hear them all. Administrators might be astonished to know, though, just how many complaints slip past their notice.

Data from Technical Assistance Research Programs, a D.C.-based research concern, found that just 5 percent of dissatisfied consumer complaints ever make it to management’s attention. A further 45 percent of complaints reach frontline staff, who then may fail to convey it up the leadership chain. Most dismayingly, 50 percent of dissatisfied consumers have complaints—but choose not to voice their concerns at all.

This has some disconcerting implications. These numbers mean that, for each concern a long term care administrator hears about, nine may stop with nurses or nurse assistants, and 10 more are never heard by anyone.

Administrators can be forgiven if they feel some frustration at this. How are they supposed to address complaints that they never even know about? But consider how difficult it can be for a resident or family member to speak up in the first place.

Most people prefer to avoid conflict, not generate it. Residents or family members might feel too intimidated to tell someone that they’re unhappy. And even if they muster up the resolve to complain, they might not know to whom they should talk.

Heartbreakingly, even if they’re deeply dissatisfied, and they know exactly who to tell about it, they might not bother, because they don’t believe it would help. Disappointments in other industries, or even within long term care, have taught them that their complaints rarely make a difference.

All this means that administrators should re-examine their assumptions about who’s complaining at their facility. What they hear is just the tip of the iceberg. There are more complaints—many more of them—than administrators might think.

What Moves Complainers

This iceberg effect compounds administrative uncertainty in another way: It makes it much more difficult to identify causes for complaints. If administrators hear only a tiny fraction of complaints, they can’t be certain that what they’re hearing is really representative of their community. If that’s the case, how can they identify what makes residents and family members unhappy?

It’s not a trivial question. Fortunately, where complaints fall short of certainty, other data can point the way.
Most administrators are familiar with Net Promoter Score (NPS). The score represents how many residents are likely to recommend a community to their peers. It’s an excellent proxy for overall satisfaction; recommenders are extremely unlikely to have many service complaints. This means that anything that boosts a community’s NPS is also likely to reduce complaints. The next step is to identify what behaviors from staff increase NPS.

Research from NRC Health does just that. Its data show that, for residents across the entire continuum of long term care—from short-term rehab stays to permanent residencies in skilled nursing centers—“care/concern of staff” is very highly correlated with high NPS scores.

In statistical analysis, the “correlation coefficient” is a measure of how strongly related one figure is to another. Anything higher than a 0.50 is considered a robust correlation. And in assisted living communities, for example, the correlation coefficient between reported “care/concern of staff” and overall NPS score is 0.58. For short-stay residents, it’s 0.77.

These figures are much the same with family members. For them, “care/concern of staff” is the single measure most highly correlated with high NPS scores, with a correlation coefficient of 0.76 at skilled nursing centers.

This raises the question: Which staff members are under discussion here? Where and by whom is this “care and concern” expressed? The answer should be clear enough for most administrators. It’s certified nurse assistants (CNAs).

The Most Important Relationship

Among employees at a typical long term care community, CNAs have by far the most frequent interactions with residents. They deliver almost 90 percent of all care activities, according to a 2008 review in Qualitative Health Research. They’re privy to some of the most intimate and vulnerable moments—think of toileting, dressing and undressing—in residents’ daily lives. It stands to reason that most of a resident’s perception of compassionate care is derived from how CNAs interact with them.

Unfortunately, this is where the problem lies. A 2016 article published in Burnout Research found that CNAs are some of the most overburdened and burnt-out workers in the entire American workforce.

Caregiving is a very demanding profession. Having responsibility for the care of some of the frailest members of society carries with it a heavy burden of responsibility. This can result in job stress, unless management takes steps to create a compassionate culture where everyone cares for each other. Due to the extraordinary levels of job stress experienced by CNAs, turnover rates for them are staggeringly high.

Through no fault of their own, this makes their work much harder. Chronic workplace stress hobbles their ability to bring their most patient, compassionate selves to their work. Though these frontline caregivers are a community’s foremost ambassadors, the work of caregiving for some of society’s most vulnerable, compounded with the stressors that come with the work, frequently stretch them beyond all reasonable capacity. 

CNA stress is a complicated issue that has no easy resolution. Not every element of a CNA’s distress is under management’s control. But management can make the problem better or worse.

Data from NRC Health show that two behaviors from their supervisors can make all the difference: “care/concern of management” and “attentiveness of management.” These management behaviors have very high correlations (0.69 and 0.66, respectively) with CNAs’ reported willingness to recommend their communities as places to work.

In short, CNAs who have caring and attentive managers are much more likely to report feeling satisfied with their jobs. This, in turn, means that they’re less likely to be acutely distressed as they interact with their residents—and much more able to deliver compassionate care. This means that the most important relationship in long term care might be between the CNA and the charge nurse.

An impatient or curmudgeonly charge nurse will likely see those behaviors echoed in the way that CNAs treat residents. But an empathic and patient charge nurse can help their CNAs breathe a little easier and bring those nurturing qualities to the point of care. It’s “trickle down compassion”—and it’s very powerful.


Given all of this, what should administrators do? Here are three recommendations.
  • Explore the complaint iceberg.
Communities should have clear mechanisms for fielding complaints. Administrators should do everything possible to ensure an unobstructed flow of communication from the resident, to the frontline, to management—and in the reverse direction as well.

They should post notices that explain how residents and family members should deliver their concerns. Frontline staff should be trained to handle these complaints when possible, and encouraged to report them to management.

Even these measures are unlikely to catch every complaint. It’s also important to consistently field satisfaction data from residents and family members, in order to capture anything administrators might be missing.
  • Resolve as many of the complaints as is possible.
One upside to complaints from residents is that, if they’re well addressed, they can win enduring loyalty from the complainant. A customer who complains and gets the complaint resolved is 30 percent more loyal than a non-complainant, and 50 percent more loyal than a dissatisfied complainant.

These resolutions needn’t always be costly or complicated. Sometimes all it takes is a 90-second, sincerely apologetic interaction. Other times it might require more drastic intervention. In either case, administrators should commit themselves to resolving every complaint they know of—because they might never know how many other complaints are below the surface of their attention.
  • Address most complaints’ root cause by showing compassion to employees.
This may be the most important step of all. If managers are to have any hope of increasing resident satisfaction, they need to model the kind of compassion that they expect their employees to deliver.

This means showing attentive concern for employees’ feelings, attending to their needs as they arise, and—yes—sparing every bit as much care to employee complaints as to customer complaints.

It’s a simple lesson, but hard to execute: What goes around comes around. But if administrators can
commit to it, they’ll be that much closer to seeing their staff thrive, and their residents alongside them.
Mary Tellis-Nayak, RN, MSN, MPH, is a consultant in post-acute care for NRC Health.