Worth? What's good caregiving: there are myriad ways to show how much you value your frontline caregiver. Ready to walk the walk? (Frontline Caregiver).

DELINEATING THE REASONS WHY THE frontline caregiver deserves a high level of respect and admiration is easy. Finding the right way to show this respect and admiration is not.

It's not that administrators don't want to lavish attention and rewards on their frontline caregivers. It's that often there are limitations--cultural limitations; financial limitations. Then there's the longevity factor: Most frontline caregivers hired today will be gone by the beginning of next summer. And many will not last until even this Thanksgiving.

But it is the appropriate giving of thanks that must take place to slow the revolving door that has characterized the entrance (and exit) through which so many frontline caregivers pass. Contemporary Long Term Care recently asked several industry experts how to stem the tide of frontline caregiver farewells. Their wish list of solutions contained no real surprises: better wages and improved benefits. What was surprising was that sometimes the frontline caregiver is her own worst enemy. What can be changed? What can't? Here's what the experts had to say.

Lorraine Tarnove, executive director of the American Medical Directors Association based in Columbia, Md., says that of all the research that's been done, "money" and "recognition" keep vying for first place in the race of how best to reward employees. "Any award--such as Contemporary Long Term Care's 'Order of Excellence in Frontline Caregiving'--that recognizes these frontline caregivers is great," Tarnove says.

"What naturally emerges in teams at the facility level is its own reward," she continues. "But the field has to go beyond that. The assumption of the frontline caregiver is that she is invisible. To get the type of people who we need to do these jobs requires more than one simple answer. We need a comprehensive approach that looks at work environment, wages, recognition, and training."

Tarnove adds: "It was disappointing that a recent staffing report released by the government didn't include a national call for change. When you're trying to change something as big as the long term care environment, you need everything to line up from the national to the local level. Without that, it's hard to make anything else happen. The only thing that's going to make this need rise to the top now is just the sheer demographics--look at the number of baby boomers moving into long term care. That will be a pretty powerful tsunami behind the change," she speculates.

"The nursing home industry as a whole has had an abominable turnover rate," says Sheldon Goldberg, president and CEO of the Jewish Home & Hospital Lifecare System, with three campuses--one each in Manhattan, the Bronx, and Westchester. Despite the fact that the Jewish Home team must be doing something right--Goldberg projects his turnover rate at only about 10 percent, reportedly well below the turnover rate of most facilities in the United States--still, he says, "it's a national issue. I don't think there's a facility in the metro New York area that's fully staffed with nurses." To maintain staffing ratios, the Jewish Home is bringing in nurses from as far away as the Philippines, which he says is not an uncommon practice.

"Everyone's paying bounties," Goldberg says. "People are paying in the neighborhood of $5,000 finder's fees. Almost every institution is paying something extra. There's an incentive for the employee who brings in the new nurse, as well as an incentive paid to the new nurse being hired," he explains.

"Looking at the development of new pools of labor is a real concern," echoes Robyn Stone, executive director of the Institute for Future Aging Services at the American Association of Homes and Services for the Aging (AAHSA).

"It's fundamentally wrong when the pizza delivery guy gets paid more than a CNA," says Good Shepherd Services and Wellspring Innovative Solutions Executive Director MaryAnn Kehoe, Larry Minnix, AAHSA's president, adds: "Retention is a much bigger issue than recruitment."

So how are you going to find these new employees? And once you find them, how you gonna keep 'em down on the farm? In addition to sign-on bonuses and finder's fees, there are other come-ons. "There are incentives that we're looking at that we never had to look at before," says Goldberg, "such as offering flexible work schedules."

Stone believes respect for the position needs to change in the public eye. "I think it starts with the public," she says. "We do not have an appreciation for the work that these folks do. Consequently, their image is [devalued]."

REACH OUT AND TOUCH SOMEONE

Want to know how to make an RN or a CNA happy? Ask them! (See "Can you develop award-winning frontline caregivers? Yes you can!", below.) "I'm seeing suggestion boxes and a culture change that increases the involvement of the staff wherever I go," says Minnix.

Goldberg's facilities have them. "We're interested in how to make it a much more enjoyable environment," he says. (See "A friend in the Unions," page 37.) "For instance, we always hear from our staff how much they hate the constant charting they have to do. In long term care they have to chart things all the time. So we're looking to technology for help."

The Jewish Home is experimenting with a beta test: In its Bronx campus, the staff on select units has gone to a paperless charting system. "We even have a computer on the medication cart," Goldberg points out. "The goal is to make the nursing experience less laborious with the paperwork and more fulfilling by allowing them t spend more time talking to the resident," he explains. The test currently involves the night shift on four units: two subacute units and two long term care units.

Is it working? "The staff members say they are having some problems with the new system, but they don't want us to take it away! They love it," Goldberg says.

The staff members at the Jewish Home have a voice via the "Bright Ideas" program in place there. This is composed of a suggestion box in each of the three campuses, along with a Performance Improvement team member at each of the facilities.

'STAFF' OF LIFE

"We celebrate the best ideas with a luncheon annually," Goldberg says. "Culture change is the most important change we're trying to effect. Ours is a very top-down-oriented profession, managerially speaking," Goldberg explains. "Employees probably laugh at how uninformed we are. So we're trying to make the process one where everyone--including the resident--has a say in what's being done."

He continues: "We've received hundreds of ideas this way, and we've implemented so many of them." For instance, at the behest of its staff members, the Jewish Home has added an ATM machine right in the facility. Staff members are encouraged to participate through reminders at meetings, employee newsletters, and memos.

Stone takes it a step farther. "This isn't just about annual luncheons," she says. She's interested in inspiring and culling "significant initiatives." To that end the Institute for the Future of Aging Services has created a national clearinghouse on recruitment and retention practices. While not fully operational as of press time, the domain for the site is http://www.directcareclearinghouse.org/ltcworkforce and it intends to be a compendium of "best practices" that focus on recruitment and retention of frontline workers in long term care.

"It will focus on what providers are doing," Stone says. "We have been soliciting these best practices that have some evidence of success." To make the grade, the practice's practicality needs to be quantifiable and documented wherever possible. "We don't want to talk about the success of any practice unless it has some evidence behind it," she explains.

There are some who are doing it quite well. Of particular note is Wellspring Innovative Solutions, a cooperative effort between two Wisconsin organizations, the Evergreen Retirement Community in Oshkosh and Good Shepherd Services in Seymour. Eight years ago Good Shepherd's turnover rate was 110 percent; now its turnover rate is 17 percent and it has a retention rate as high as 98 percent.

"Managers have been trained in the model of control," Kehoe says. "The nursing process is based on control [now] rather than giving up control in exchange for greater control later on," she illuminates. Wellspring's goal is to change all that.

How? By giving control and education back to the frontline caregiver. Kehoe believes that the current system of nursing home care in the nation is broken. Long term care facilities are in crisis in terms of quality of care and availability of staff. The typical organization, she says, has an autocratic management structure with high staff turnover and low staff morale.

"When your frontline caregiver understands the intricacies of the care she is providing, she can be more efficient in her role. That means the quality of life for both the resident and that staff member is improved. When she sees the difference she can make, and takes ownership of her accountability for that difference, it improves retention as well," Kehoe explains. (See "The relevance of education," page 38.)

Wellspring Inc. is a 501(C)(3) not-for-profit corporation. The charter Wellspring group is an alliance of 11 independent not-for-profits with SNFs ranging in size from 63 to 415 beds (with the average home having 135 beds).

FRONTLINE WORKER, HEAL THYSELF 

Is it enough to try to change the corporate culture simply by giving staff members a forum to be heard, or by allowing more decisions to be made at the frontline level? Our experts say no.

There's no one entity responsible for the frontline care-giver's minimized stature, says Stone. "In addition to the public having a responsibility, and management's role in showing a greater appreciation, public policy can help, too, by allowing us to increase what we pay these workers, and by what types of training can be made available. The media have a responsibility as well," she points out.

Stone is also quick to uncover that the frontline caregivers themselves bear a share of the responsibility. "Frontline caregivers eat their young," she says. "The fact is these folks, who are unempowered themselves, tend to devalue the newer people coming into the profession. There are some real issues here."

She continues: "Everyone wants to flatten the hierarchy in what they refer to as 'culture change.' But there should be no incentive to one-up a coworker. Nurses aren't trained as managers. They're trained in a very hierarchical environment themselves. When the nurse/frontline worker relationship is bad, and when nurses do not delegate well, then that affects turnover and retention rates. So the focus on 'management' and creating a work environment is really key."

Can't we all just get along? "There is a lot of finger-pointing regarding who has dropped the ball," Stone goes on.

"I say just start from where you are."

"I think there is a three-tiered responsibility for how you reward and recognize frontline caregivers," says AAHSA's Minnix. "The first one is to recognize that the commitment and the compassion of the vast majority of caregivers are internally motivated. (See "Who makes a difference in long term care?", at left.) They don't do this job unless they have a real calling for it. It's not just a job. It's arrogant to think we can motivate this type of commitment. These people are a blessing in the field of aging and health."

He adds, "There's a tendency to think of them as 'the help' and we just can't get enough 'help? But many of these people have been called to do this work. What the public and the government and providers have a responsibility to do is recognize that these are special people."

How? "That's the second tier: Government and provider reinforce them through wages, benefits, and training," Minnix details. "The payment is just not enough to respect the work these folks do. We need to recognize that where the money needs to go is to the paid caregiver as well as the volunteer caregiver. The money needs to increase. And it's starting to be done at the local level. Pay people a living wage; pay for their training."

And the third tier? "We have to think about how to elevate the profession over time. Hairdressers in most states are required to get more training, and are paid to get more training, than frontline caregivers are paid to do their job. We've got to increase their competence in assessment and treatment skills so they feel more empowered and confident to respond to resident needs."

Minnix concludes: "Our association, along with the American Health Care Association, is committed to a concerted approach to upgrade the field. A key element is to recognize, reward, and support the primary frontline caregivers."

RELATED ARTICLE: Can you develop award-winning frontline caregivers? Yes you can!

Contemporary Long Term Care asked Advisory Board member Janice Olson, RN, MS, MEd, how she feels the frontline caregiver should be recognized:

How can an administrator develop award-winning frontline caregivers? It takes sound management and leadership skills, good instincts and some luck!

Several years ago the facility where * was director of nursing received a Best Practices in Human Resources Award from the Brookdale Center on Aging and the American Society on Aging for the nursing department's quality initiative. Ongoing measurements showed high staff satisfaction with the work environment while also improving resident outcomes and satisfaction.

Some strategies we used to help our staff perform their best:

* Empower staff by giving ownership. Involve them in designing the care delivery system, and day-to-day decision-making. Develop a vision of what the department is about and have systems in place to support it. Have clear job descriptions that enable staff to do their jobs. Give the authority needed to match their responsibilities and accountabilities. Use permanent resident assignments. Avoid micromanaging.

* The administrator is the staff's leader, not adversary. Provide them with the resources they need to do their job--training, supplies, equipment, and information! Share outcome data regularly--it helps them see what they've achieved and to set new goals.

* Make every day Employee Appreciation Day! Compliment their achievements openly and honestly and watch them bloom. Show them how much they're valued.

* Teach staff to provide quality care by following professional standards of practice that do what's right for the resident. A regulation-driven mentality stifles creativity and promotes fear. When quality care is being given, the regulations should be met.

What pleasure to work with a staff of award-winning caregivers!

A friend in the Unions

Facilities shouldn't feel that they're fighting the good fight alone. Many have found a friend in the Unions.

"To make our process more efficient, and in response to our staff members who took the time to tell us what they'd like to see differently, we've implemented a beta test at our Bronx Campus to create a paperless charting system," says Sheldon Goldberg, president and CEO of the Jewish Home & Hospital Lifecare System. "Everybody in this field understands that there is a massive amount of note-taking required. I'm not saying it's bad, I'm just saying it's a lot. So now we have portable and desktop computers. On the med carts we have broadband radio communication and battery-operated hardware. Physician orders can be given right through the computer. Much can be done through the system. All the systems development and debugging is going on at the Bronx campus. And there is a huge need for training to make this happen."

He explains, "We brought in kiosks in the dining room where the people could play on the computers. A number of people already had the necessary skill set. But we couldn't do this alone. Our partner was the Union: Service Employees 1199. Its senior people and shop stewards put in a lot of investment and training to make this happen," he says.

"We also have very good benefits (health care, disability insurance, and pension plans) and all because of the dynamic relationship with our Union. The Union fought the battles politically," he adds.

American Association of Homes and Services for the Aging President Larry Minnix concurs: "One of the things that we have found out here in Washington is that we have some of the same goals for the primary caregivers as those of the Unions, particularly regarding wages, benefits, training, and recognition. So there are certainly common interests there. Our history of working with them has been spotty around bits and pieces of legislation. But we have a common agenda."

Who makes a difference in long term care?

"The people who are able to make a difference in long term care at the frontline are those who are not afraid to care. This would include the CNA, housekeeper, dietary aide, maintenance person, LPN, RN, Administrator, SW Activities, to name but a few. Long term care is a very intimate setting that requires people to cut through perceived barriers that exist personally, professionally, or socially and get in touch--literally and figuratively--with those for whom they care. Giving of one's self and getting close to another person is the most important thing in long term care. The relationships that form make all of the difference. This is a difficult concept that goes against much of our professional and social norms, where we are taught to be distant and efficient and detached, and to fragment every task into its smallest component. Putting the CARE in caregiving means that these individuals are able to give of themselves in the very intimate world that is long term care. This extends from CNA to resident, fro m supervisor to employee, and from administrator to department head. In the end, long term care is not an arm's-length specialty. It is up close and personal and often messy and emotional. These features are often scary for many people. Those who do this well generally do it instinctively and are able to, by example, impart their values to the others around them."

--MARIE C. INFANTE, RN, MS, MBA, JD, CLTC ADVISORY BOARO MEMBER

The relevance of education

According to Mary Ann Kehoe, executive director of Good Shepherd Services and the Wellspring Initiative, if the caregiver is to get her due, then there needs to be a re-education of everyone in the long term care community. Providers need to learn how to give frontline caregivers more freedom and decision-making ability, she says. And nurses need to learn how to better apply what they've learned at seminars and conventions.

Moreover, among the best ways to increase caregiver stature and retention as well as reduce turnover is to make frontline caregivers accountable for outcomes regarding their residents. Give them the tools and ability to feel important, she says. This starts with getting the buy-in from administrators regarding "the relevance of teaching frontline caregivers how to collect relevant data," she says. "We need to teach them how to evaluate information critically and implement processes to improve care."

She continues: "I believe the key to success with this is in educating providers on the value of unit-based management. There should be permanent groups of staff assigned to the same group of residents. This way anyone--nursing, housekeeping, foodservice, anyone--who comes into contact with Mrs. Jones can detect early on if she isn't quite right, or isn't quite herself," she says. "So let's stop the rotation of staff."

"Second, make staff members accountable. Third, give frontline staff in all departments training in the clinical areas so that they understand the different processes with older adults," she says.

"So if you give them the clinical education, then they understand their own value. Make them responsible for the outcome of care." Kehoe concludes, "This also creates a neighborhood based on relationships. That's when there is a strong bond being forged, and that's when the real magic happens."