Long-Term Care

Tip of the week: Three ways nursing homes solved their staffing problems

Contemporary Long-Term Care Weekly, August 21, 2008

Nursing homes across the country have devised innovative practices to address some of their most pressing problems--including ways to attract, train, and keep staff.

These best practices were the subject of an Office of Inspector General (OIG) report, Emerging Practices in Nursing Homes, released in spring 2005.

In its study, the OIG set out to look for and observe emerging practices, which it did by visiting 16 nursing homes in various parts of the country. The agency selected the nursing homes based on the results of their state surveys, recommendations from national nursing home organizations, and innovative practices described during initial telephone interviews.

The OIG focused on ways to strengthen staffing because many nursing homes have high staff turnover and find it difficult to attract, train, and retain an adequate work force. The following are some of the solutions nursing homes have initiated to solve staffing problems:

Establish a mentoring program. Eleven of the 16 nursing homes the OIG visited had such programs for their certified nursing assistants (CNA). The nursing homes train experienced aides to provide peer leadership to newly hired CNAs. Facilities provide training to mentors in leadership, communication, teaching, and conflict resolution.

Typically, a newly hired CNA observes and learns from a mentor, gradually taking on more responsibilities and gaining independence, the OIG said. The mentor consults with nursing home managers about the new CNA's progress and evaluates and keeps track of the skills learned by the new employee. The mentor helps the new CNA become acclimated to the facility and works with the CNA until he or she is ready to work alone.

Mentors can also


  • conduct inservice training for other staff


  • help orient new employees in nonnursing jobs, such as dietary and housekeeping staff


  • participate in the hiring process (e.g., by touring the nursing home with prospective employees)

    "Establishing a mentoring program requires a commitment of time and money," the OIG report noted. For example, mentors spend time away from resident care when they undergo training, or they may care for fewer residents. Therefore, nursing homes must hire additional staff to care for those residents. Mentors may also earn more than other CNAs, typically 50 cents to $1 more per hour.

    The cost may be worthwhile. "Despite these costs, managers at nursing homes we visited attributed improvement in staff retention to the use of mentors," the OIG said. Retention can lead to increased quality and continuity of care. One nursing home administrator said mentoring led to a decrease of almost 50% in CNA turnover, the OIG reported.

    Involve staff in decision-making. Two of the nursing homes that the OIG visited train staff to participate in quality improvement (QI) programs.

    At one facility, managers, dietary staff, nurses, and housekeepers receive classroom training about data analysis and critical thinking skills. Class members then apply the skills to a specific project identified by management. "Staff who complete the course are empowered to solve problems close to the resident level and are considered 'floor leaders,' " according to the report.

    At the other nursing home, ad hoc teams made up of staff from different disciplines conduct QI projects. Managers charge teams with improving a specific area of the home's operations.

    At three other homes, CNAs, dietary staff, and activities staff serve on committees that focus on QI, safety, restraint reduction, and wound care.

    Although participation takes staff away from resident care duties, managers said drawing on the knowledge and experience of staff can help improve quality of care and life for residents. An additional benefit is increased job satisfaction and staff retention because employees have input into facility operations.

    Maintain flexible work schedules. Seven nursing homes offer flexible or nontraditional schedules to their employees, the OIG said, which allow staff to attend to personal matters.

    Two facilities also offer flexible schedules to staff who pursue advanced degrees, such as registered nurse programs.

    How do the flexible schedules work? One nursing home operates two 12-hour shifts for nursing staff, instead of the typical three eight-hour shifts. Workers come in from 7 a.m. to 7 p.m. or 7 p.m. to 7 a.m. Another home allows employees to work two 16-hour shifts on the weekend and pays them for a full 40-hour week.

    At the home that operated on 12-hour shifts, family members like having two CNAs care for residents because it provides more continuity of care. CNAs who work the day shift said they spend the earlier part of the day providing hands-on care, but in the afternoon they can spend more time visiting with and getting to know residents.

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