Recruiting from within: reducing burnout and turnover.

It's hard to believe, but a home-baked chocolate chip cookie led to an annual turnover rate one-fourth below the national average for LTC chains.

Given the Shawnee, Kan.-based The Sweet Life's sugary name, the chosen turnover reduction method seems all too appropriate.

Every day, as employees clock in, a cup of coffee or cappuccino awaits, while the scent of a fresh-baked item hovers in the air. "They're two of the little perks we give," said Kim Ellis, Sweet Life's administrator. "We truly believe that you should feel good about coming to work."

Cookies alone didn't help reduce the company's turnover rate to less than 25 percent per year, according to Ellis. It's a case of keeping the employees happy. "In this industry, it often feels like the workload is too much, and no one cares about you or respects you," Ellis said. "Employees want to feel liked; they want to feel listened to."

Otherwise, staff can feel burned out by their jobs, according to Thomas Lohuis, chief executive officer of The Wellspring Institute in Green Bay, Wis.

That, ultimately, will lead to one thing the industry doesn't need: "They quit," Lohuis said. "Your good people will leave. What you're left with are mediocre people, or people who have no problem taking shortcuts when doing their jobs."

What me worry?

The severity of the LTC industry's turnover problem varies by survey--for example, the Alzheimer's Association places the annual national rate at 94 percent, while compiled data from 40 states puts the rate at 40 percent to 100 percent annually, according to Dr. Barry Bittman, director of the Mind-Body Wellness Center in Meadville, Pa. Meanwhile, the American Health Care Association places the rate at 50 percent for all LTC divisions except certified nursing assistants (CNAs), where turnover is 71 percent.

The national turnover rate for all jobs is 8.4 percent, according to Sibson Consulting in Los Angeles.

Quick turnover means facilities are often short-handed, meaning potential reduced care levels and increased job dissatisfaction levels for existing work staff, experts noted.

"We kept a lot of people we shouldn't have because we needed bodies," said Sr. Mary Bertlar, director of nursing at St. Paul's Elder Services in Kaukauna, Wis. "But keeping people who really weren't qualified or who didn't have the fit of our mission just frustrated those who did. Those good people would quit to go work someplace where they could share the load instead of carry the load."

It's expensive all around. According to the National Citizens' Coalition for Nursing Home Reform, it costs a facility an average of $4,000 to hire and tram a new employee. Margaret Dyekman. senior consultant at Sibson Consulting in Phoenix, called that number conservative. "We find it usually costs about half of an employee's annual compensation and benefits to replace them," she said. "By the time you get to the executive level. it's usually much higher due to severance agreements and other issues."

Meanwhile, the Institute for the Future of Aging Services estimated high turnover costs federal, state and local governments--and ultimately taxpayers--$2.5 billion annually.

"The bottom line," Dyekman said, "is that you need to do as much as you can to keep the worthwhile employees you have, and keep them happy."

Why they leave

"Rewards of Work," an attitude survey of 1,200 workers in all employment fields by Sibson Consulting, identified five areas that can result in job stress or dissatisfaction: Direct and Indirect Financial, Career Work Content, and Affiliation.

* Direct Financial means the basic monetary issues, such as salary, incentives, ownership and pay process, according to the study. While this is important in the LTC industry--CNAs, for example, typically make $8 to $14 per hour, according to Corp Trainers Institute in Newark, Del.--workers are more likely to become disenchanted with their jobs based on the Indirect Financials you offer, Dyekman said.

* Indirect Financials include benefits and non-cash recognition, Dyekman said. "It can get pretty frustrating to work somewhere and never get a pat on the back," she said.

When employees in the "Rewards" study were asked what it would take to leave their jobs, 75 percent said they would go if another company offered them an extra three weeks vacation, according to Dyekman. "They weren't as interested in stock options or a raise," she said. "Just being able to have that extra time off and freedom--especially when we all live such busy lives now--was very appealing."

Employers should find the idea appealing, too, Dyekman added. "That extra time off doesn't cost as much as a 20 percent raise," she said.

Still, that doesn't stop some facilities from relying on the tried-and-true. "We're extremely competitive in what we pay," said Sweet Life's Ellis. "it also helps that we're privately owned, so we don't have to go through a major chain of command for approval. If we want to bring someone in at a certain pay rate, we can do it."

Bertlar at St. Paul's said her facility also increased the CNA pay rate to develop a more stable workforce, which for years had been supplemented by employment agencies. "We told the nurses right up front that we wanted to get rid of agencies," she said, "and we set a target date. Four years later, we're practically agency-free."

St Paul's annual turnover rate has also dropped from 45 percent to about 30 percent--despite the facility expanding its workforce by about a third, Bertlar said.

* Career refers to how much advancement and personal growth exist in the job, as well as job security. While the latter isn't likely to be an issue, given the industry's labor-tight state, just offering employment isn't going to keep employees with you for years, experts noted. "When you look at turnover in long term care, most of it is not attributable to a change in salary or money," said Mind-Body's Bittman. "It's non-financial factors that seem to determine whether the person will stay with the job."

* Work Content includes satisfaction about what the employee is doing on the job: the variety, challenge, autonomy and meaningfulness of their work, the study noted. Autonomy tends to be the big issue in the LTC industry, according to Wellspring's Lohuis. "Most (LTC workers) get into it because they want to make a difference," he said. "In order to attract and retain people, you have to allow them to make that difference."

Lohuis said a typical complaint by lower staff is lack of communication with managers, who routinely develop procedures that make little sense to those having to carry them out. "There gets to be a lot of frustration in that these end up being a series of tasks," he said. "(CNAs) don't understand what these are or why they're doing them. You need to give them the information needed to start Looking at the processes and improving them."

True to the Wellspring philosophy, St. Paul's Elder Services asked its nurses how their jobs could be improved. Their responses included scheduling flexibility, a manageable workload and professional accountability. So the facility hired additional nurses, left scheduling up to individual nursing teams and gave CNAs the power to choose their new supervisors. "We wanted the employees to invest in their own success," Bertlar said.

* Affiliation is the "feeling of belonging" to the company, and the sense that the company values you, according to Dyekman. "It could be as basic as hearing that employees want another refrigerator," she said. "So you buy another refrigerator for $800 and people say, 'Wow, they listened to me--the company really cares.'"

Ellis said her staff learns everyone's name at The Sweet Life. "You need to address staff by name and find out little things about their lives," she said. "Little comments--'Hey, bow's the baby? I heard she was sick'--show that you know what's going on and that you care."

What's on your mind?

Employee turnover and burnout can be minimized with three simple words: How are you? Unfortunately, not everyone thinks to ask employees what's on their minds, according to Mind-Body's Bittman.

Dyekman recalled a focus group conducted by a health care employer who asked employees what could be done to better motivate them and keep them from leaving. The employees suggested things like having casual Mondays instead of casual Fridays, because it was "harder for them to come in to work after the weekends." They also asked for more time with their supervisors, or to at least know their supervisor's schedule, and they suggested a promotion level that offered a bit more of a career path. "The company's turnover went down, and it paid very little extra to make these changes," Dyekman said. "And it started by just asking employees 'what really matters to you?'"

In contrast, Bittman cited a response from a study at an LTC facility where a housekeeper commented, "You have no idea how hurt we are when someone passes on ... we have no way of communicating our feelings for that individual to the individual's family."

"These people, who had daily contact with that resident, aren't asked how they feel," Bittman said. "So they don't say anything. They go into a corner and cry."

That study, conducted in 2002 at Wesbury United Methodist Retirement Community in Meadville, Pa., featured a non-traditional approach in getting in touch with employees. The facility's staff used music to communicate their feelings about work-related matters and to relieve stress. The weekly, hour-long sessions have employees tapping away on Yamaha Clavinova digital pianos and Remo hand drums in response to questions like "what did you bring to work today that nobody knows about?" and "how did you feel the last time a person on your shift did something wonderful?" according to Bittman.

The study met initial resistance--"People were practically brought in kicking and screaming," according to Clawson. But the overall effect has been so "phenomenal" that Wesbury continued the program after the study ended in 2004. The facility's annual turnover rate dropped from 75 percent to 30 percent, and the staff gets along better, Clawson said.

"There's one employee here that didn't relate to anybody in the beginning. Now he's turned into almost a star employee," Clawson said. "People relate to him better; he does things that people were afraid to ask him to do before. It's a healthier atmosphere."

One size does not fit all

Making your facility a happier place is not always easy--mostly because every place is different, experts noted. "What works for one company is not going to work the same for someone else," Ellis said. "You've got to find out what makes your employees tick, what gets them going, what keeps them happy."

Whatever you do must be done well, she added. "If you're going to offer your employees a free lunch, it can't be a peanut butter and jelly sandwich," she said.

Make sure everyone takes part in the action. "Whether it's a fun game or a potluck, my staff will participate," Ellis said. "If it's a St. Patrick's Day potluck, you can bet they're all going to be wearing green. If nobody from above does it, why would the staff be into it? It has to trickle down from above."

RELATED ARTICLE: Signs of burnout.

When is a caregiver suffering from burnout? Probably sooner than you realize, according to Zoran Basich, a Glendale, Calif., legal expert specializing in LTC matters.

Basich, president of Nursing Home Solutions, a company that helps families obtain federal benefits for nursing home care, said the constant stress imposed by caring for one (or more) elderly persons manifests itself in various ways. Some may not be immediately obvious, but all can be detrimental to the well-being of the caregiver and the care recipient.

Caregiver burnout signs include:

* Constantly snapping at the care recipient, even over fairly minor issues;

* Complaints of feeling constantly irritated, grumpy, tired or pressured;

* Lost interest in personal activities or friends;

* Feeling "isolated";

* Complaints of losing sleep or inability to sleep well;

* Frequent yelling and screaming, or having crying fits or rages of anger;

* Withholding affection and feelings of goodwill toward care recipients;

* Constantly blaming the care recipient for "being in this situation";

* Refusing to go out or take a break because the resident "needs me";

* Recurring health problems, such as headaches, high blood pressure, asthma, nervous/queasy stomach or bowel problems;

* Out-of character, chronic lateness or absenteeism.--AN