We grow staff, not just wheat, in Kansas. (Not-for-Profit Report).

Staffing shortages are always serious, but when they affect long-term care facilities in underpopulated rural areas, the results can be disastrous. To maintain its staffing levels, Mennonite Manor, in South Hutchinson, Kansas, had to contract agency personnel. As administrator, I soon discovered that the staffing situation was getting worse--not better--and costs kept rising. In 1999, a total of $108,000 in agency fees were accrued; the following year that expense topped out at $168,000. Acutely aware of the limited labor pool that we could draw upon and the potentially devastating financial effects of continuing to use agency staffing, we took a new approach and began to "grow our own staff."

To relieve our skilled caregivers from routine tasks that take time and attention away from residents, the Manor Care Attendant (MCA) program was developed and presented to the community as a "first step" employment opportunity in healthcare. Qualification requirements are minimal: Prospective candidates have to be at least 16 years old, able to read and write, and able to comprehend our policies and procedures. Because this position does not require previous work experience, not only could we seek referrals from staff to recruit from their friends and family, but we could also promote this position to high school and junior college students interested in a healthcare career. As an incentive to spread the word, staff received a recruitment bonus if someone they referred stayed on the job for at least six months.

The MCA hiring process is consistent with the facility's general hiring practices, except that either a unit manager or the director of nursing is included in the interviewing process. Prior to acceptance, the recruit is given a facility tour; then an orientation nurse goes through an orientation handbook and supplemental material that explain the duties of an MCA.

After orientation, the MCA is placed with a nurse aide team consisting of two GNA trainers and monitored by a charge nurse. We've found that by training with CNAs in a team approach, the MCA learns to perform tasks as assigned and gains respect for supervisors and coworkers. In turn, MCAs feel their opinions are important, and they are encouraged to share their ideas.

When the program first began, staff had to be briefed on what tasks an MCA could and could not do. MCAs do not provide hands-on care to the residents. To emphasize and remind staff of this, MCAs carry laminated cards that specify their job duties. Their primary function is to assist aides whenever possible. For example, with MCAs providing wheelchair escort to and from activities, bathrooms, the beauty/barbershop, or other areas of Mennonite Manor, CNAs can budget their time more efficiently. MCAs also make beds, organize residents' closets, empty and clean commodes and urinals, fill water pitchers, lay out clothing and supplies, help with mechanical lifts, and visit and read to residents.

MCAs are taught how to chart resident food intake and how to assist a CNA using a lift or transfer device. The only time MCAs may directly provide hands-on assistance to residents is in the event of an emergency or if their action is necessary to prevent a fall. These "aides to aides" can also answer call lights, determine the resident's immediate need, and provide help (if it is within their job responsibilities) or summon a GNA to do so.

The first MCAs were on the job by February 2001. It didn't take long for the program to take hold. Today, enthusiasm still runs high, and staff continue to be supportive and involved with helping recruits learn their duties and acquaint them with facility procedures.

In addition, each MCA is given the time, coaching, and support necessary to acquire an understanding of the requirements and skills he or she needs to become a CNA. To help in this transition, scholarships are available for those individuals seeking to advance in healthcare.

Although MCA is a minimum-wage position, this program represents a first step on a career ladder in long-term care. Mennonite Manor offers successful MCAs scholarships for CNA books and tuition, and they can continue working at the facility while pursuing GNA certification. Because the cost of books and tuition is minimal compared to the cost of staffing from outside, providing scholarships is, in effect, a cost-controlling practice. By staffing with Mennonite Manor employees, the organization reaps big dividends in terms of savings and staff retention.

While MCA is a facility designation, once CNA training begins the title changes to nurse aide trainee (NAT I). As a NAT I, the student continues to provide MCA services and cannot provide hands-on care. However, after 40 hours of training and presentation of an instructor-signed checklist, the student is advanced to NAT II status. State regulations allow a NAT II to provide direct care while continuing with 50 hours of CNA training to meet state-established standards. After passing a state licensure test and presenting his or her license to Mennonite Manor, the student is promoted to CNA. With the proper professional nurturing, these once-"green recruits can blossom into compassionate, effective, enriched, and satisfied caregivers."

As an MCA develops, staff take great pride in their role in the MCA's development and see that person's success as part of their own. The GNA mentors have also improved their own skills and have become more flexible with their work routines, and often find value in trying to do things a new way if an MCA offers a good suggestion. Staff also discovered that MCAs were more flexible on procedure and willing to follow instruction than agency personnel, which added cohesiveness to the caregiving team.

Through this cultivation of a new level of nursing home staff, we find that optimum staffing levels are easily maintained by a team of caregivers that subscribes to our organization's mission, core values, positive attitude, and dedication to its residents--qualities that are too often missing in agency personnel.

Since the MCA program began, facility retention rates have improved dramatically. In 2001, 43 MCAs were hired, 32 went on to complete CNA training, and at year's end 29 remained on staff, a 67% retention rate. By comparison, during the same year we hired 25 CNAs, and 11 were still with us at the end of the year--a 44% retention rate. As of September 1, 2002, Mennonite Manor had hired 18 MCAs, with a 78% retention rate. Because of the quality of people in the program--both the students and coaches--we were able to discontinue the use of agency personnel as of September 2001. Growing our own staff has produced a bountiful harvest.

Judith Wineland is the administrator at Mennonite Manor. For further information, call [phone]. To comment on this article, please send e-mail to [e-mail].