Everything You Know About Skilled Nursing Hiring is Wrong

Hiring and retaining talented skilled nursing employees remains one of the biggest challenges for operators in the industry, especially for key frontline nursing positions.

Amid these pressures, hiring managers might be tempted to rely on their instincts when selecting from potential candidates — but two health care staffing experts say in many cases, conventional hiring wisdom is wrong.

Trey Mullins and David Wilkins, speaking at the American College of Health Care Administrators’ annual convocation in Orlando, Fla. last month, presented compelling data showing that key hiring metrics such as job experience and years of education have little to any validity in predicting future performance.


“You might as well flip a coin in terms of those last two variables,” Wilkins, chief marketing officer at the Woburn, Mass.-based human resources software and advisory firm HealthcareSource, said. “They’re not predictive in any meaningful way of any future performance.”

Wilkins and Mullins, HealthcareSource’s senior director of post-acute operations, cited data from a meta-study conducted by researchers from Michigan State University and the University of Iowa, which analyzed 85 years of research on hiring strategies.

“It’s really, really solid science at this point,” Wilkins said, responding to some skepticism from the crowd about the lack of correlation between job experience and performance. “Most people are unaware of how good that science has become over the last 20 years, and they don’t rely on it.”


The meta-analysis found that among a wide variety of potential metrics, performance on general IQ tests actually provided one of the most reliable correlations with future job performance.

Using IQ tests in the hiring process, however, can potentially open up employers to legal action due to a variety of discrimination issues. That’s why providers should look to work sample tests and structured interviews that include questions about real-life work situations, indicators that provide a similarly strong prediction of how the candidates will actually perform on the job.

In addition to statistical correlation, conducting structural interviews between existing employees — particularly certified nursing assistants (CNAs) — and candidates can help increase morale at a specific skilled nursing facility.

“Help them own a part of the problem in selecting new employees,” Mullins said of CNAs. “They’re going to have to work with them anyways.”

Mullins suggested providing trusted CNAs with a structured interview guide to ensure that they ask the right questions during the process, which can help frontline staff learn the importance of careful and efficient hiring practices.

“You know how it feels when somebody leaves. Let the CNAs know how it feels to own part of that issue,” he said.

Save the CNA, save the world

Retention of CNAs isn’t just about ensuring that there are enough caregivers to handle a particular SNF’s census: Wilkins and Mullins pointed to data showing that CNA turnover actually begets more turnover throughout the entire facility, and is also correlated with increases in a variety of negative patient outcomes — including use of physical restraints and catheters.

Aside from the director of nursing, CNA is “the only other role in the facility that’s predictive of other roles’ turnover,” Wilkins said.

Boosting CNA retention, meanwhile, can lead to a reduction in hospital readmissions, Wilkins and Mullins said.

“Save the CNA, save the world,” Wilkins said

Of course, that’s easier said than done — shortages of CNAs and other frontline caregivers are at epidemic proportions across the United States. But Mullins also noted that a certain level of turnover is good for skilled nursing facilities, as it indicates that the lowest-performing employees are being effectively weeded out of the workforce.

“If your turnover rate is 16% or lower, you’re keeping individuals in your company that probably aren’t up to snuff. They’re well below average in your performance curve,” Mullins said. “I think that’s going to show up in some of those patient outcomes if you have extremely low levels of turnover.”

Written by Alex Spanko

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