Fighting the Perception That Entry-Level Nursing Home Jobs Are a ‘Dead End’

At a time when more than a quarter of nursing facilities are reporting at least one staffing shortage, skilled nursing operators now more than ever have to find creative ways to establish career paths for entry-level positions that are often seen as “dead end jobs.”

Dr. Jeff Farber, New Jewish Home president and CEO, worries that some of the solutions that have been presented in the last year to help nursing homes alleviate the workforce shortage, such as immigration reform, may have the wrong mindset.

“Not that it’s a bad thing to do, but it reinforces the false notion that these are terrible jobs that no one here wants, and so we’ll have to depend upon immigration for the workforce to come in and fill those positions,” he told Skilled Nursing News.

In meetings with Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-Lasure and other top federal officials, the sector continues to provide their insights and ideas. The meetings come after the Biden administration released its nursing home reform package, recommending the creation of better pathways to good paying jobs and ensuring nurse aide training is affordable.

“I had a chance to talk with Administrator Brooks-LaSure together with LeadingAge … and the important point is that the administration is going to better achieve its goals if it views [us] as an ally, as a partner and as a part of the solution who you want at the table,” Farber said.

The nursing home sector lost 2,500 more jobs in March, as 15.2% of its total workforce has left since the start of the pandemic.

A recent survey of 69 owners and executives of senior housing and skilled nursing operations across the nation found that one-quarter of respondents had more than 20% of their full-time positions currently unfilled, according to the National Investment Center for Seniors Housing & Care (NIC).

After one year, only 17% of organizations still had over 80% remaining on the job, the results showed.

Respondents were asked to share innovative methods they found to be successful in recruiting caregiving staff beyond generally increasing wages: flexible schedules, hiring and referral bonuses and offering additional education and clinics were among the responses.

President Biden wants to lower financial barriers to nurse aide training and certification and called on CMS to establish new requirements for better notifying and publicizing to the workforce what training reimbursements and free training opportunities are available to them.

“We really need to combat the perception, and unfortunately often the reality, that these can be dead end jobs or that there aren’t opportunities to continue to advance and develop a career in the long-term care setting,” Kezia Scales, PHI’s National Director of Policy Research, told SNN.

She believes if the sector is going to come out of the workforce shortage more investment needs to be made into skill development along with commensurate wage increase, otherwise nursing assistants all the way up to administrators will continue to leave.

“It’s every job category,” Tina Sandri, CEO of Forest Hills DC, told Skilled Nursing News. “It took us more than a half year to find a social worker. Our MDS coordinator has turned over I think four times in the last year. My business office has had 100% turnover in the last three months.”

One way Forest Hills is looking to build a more stable workforce is through specialized training to establish better career ladders for its employees.

Why better training will be critical for retention

Standalone facility Forest Hills has around 200 employees with about a dozen openings currently. 

“Our director of HR tells me that up to 40% of workers are thinking about changing which tells me that about 80 people are thinking about changing jobs this year,” Sandri said. “That’s what keeps me up at night.”

She thinks the nursing home sector could take a page from other industries to make CNA jobs more attractive.

“You could be brand new that works in a restaurant and [start as] a busboy and eventually they might let you wait tables and move up into various positions based on performance. That’s not so different from a career ladder in a CNA,” she said.

Forest Hills has partnered with Suma Prime School of Healthcare in collaboration with the D.C. Department of Employment Services to build the first CNA career ladder apprenticeship program in the district. The goal is to build a program that advances CNAs in their careers, combining traditional classroom instruction with structured and supervised on-the-job learning.

“We are back to 1994 staffing levels right now and yet the number of people who need care has mushroomed since 1994,” Sandri said. “We need out of the box solutions and we need to be a village. I think the apprenticeship program helps us because we’re leveling up the skills of the CNA to care for the residents.”

Lori Porter, co-founder and CEO of the National Association of Health Care Assistants (NAHCA), said she would like to see more centralized training for CNAs, describing their continuing education as very limited.

NAHCA, together with ShiftMed, launched a new training platform dubbed the National Institute for CNA Excellence or NICE – which provides a learning management system to educate new recruits.

“We created NICE to be a professional education institute the graduates can be proud of. Certification does not do the same as outsourced education,” Porter said.

The platform first launched in Texas – with over 30 SNFs now enrolled – and plans to expand to the rest of the country.

Porter said the program has received interest from other states like Illinois but is limited by which states it can enter due to differing regulations.

“NICE is prepared right now to be a national solution. We can recruit over 100,000 New CNAs annually at NICE,” she said.

Scales thinks more can be done to strengthen career pathway opportunities for CNAs by moving them into licensed positions like an LPN or RN, but it’s a “big step” and will require significant investment.

PHI partnered with Trinity Health Senior Communities to design an advanced CNA role, a transition specialist, to provide more continuity during, before and after a resident’s stay in a nursing home. Other training that can be valuable for CNAs is dementia training, according to Scales.

“Nurses may get a small amount of dementia care training, but what if there was somebody within the nursing assistants workforce in a particular nursing home that had specialist dementia skills that was able to kind of guide and support other staff in providing high quality care for residents with dementia,” she said.

Forest Hills offers dementia training as part of its apprenticeship program as well.

“I was talking with a porter who cleans the floors and he had gone through some dementia training and I’d asked him how it helps him with the job and he said when the resident asks him 10 times why he’s there, he can answer with more compassion and not feel so irritated,” Sandri said.

Scales thinks that nursing homes’ commitment to establishing more specialist roles can expand beyond transitions and dementia.

“We could think about heart disease, stroke, depression, and other types of common conditions that we see often in one person in the nursing home. I think we need to upskill this workforce overall to make sure that they are prepared to care for residents with those conditions,” she added.

Why looking to high schools will be essential for recruitment

Nursing homes won’t be able to build better career pathways without new recruits and some operators like The New Jewish Home have had success looking to high schools to expand their workforce.

Seeing a problem without a solution, the New York-based operator took a proactive approach by creating a pipeline for at-risk youth to work in their facilities. The New Jewish Home established its Geriatric Career Development Program (GCD) in 2006, recruiting students aged 14 to 24, particularly targeting local, under-resourced high schools to work in skilled nursing.

“We have partnered with 10 public high schools in New York City and high school students come for a life skills training immersion program in the nursing home several days a week after school,” Farber said. “They build connections, relationships and then we provide training and certification in a career. There is a natural career ladder.”

Farber thinks there’s a robust appetite to expand the program out to other facilities across the nation.

The program serves 225 high school students annually and includes an alumni base of more than 700. The three-year curriculum includes college readiness, health career exploration activities, internships, professional/older adult mentors and clinical training.

What they are finding, Farber said, is that some are pursuing careers in health care and some aren’t, but the program has been successful in bringing “concrete deliverables” that are good for both the industry and program participants.

“I would love nothing more than to see the administration take a critical look at what we’ve developed as the workforce program,” he said.

Farber’s had conversations with other operators around developing hubs in their respective geographic areas to develop the relationship with their social service agencies.

“The biggest home run would be money, earmarked legislation,” he said. “Senator Gillibrand has taken a strong interest and she’s come in, visited with our students and has gotten to know our program. I know her office is actively working with us and looking at ways to try and secure funding so that we can do this for many more New Yorkers and not just New Yorkers but throughout the country as well.”