Starting From Within: How Nursing Home Operators Can Tackle Fewer Applicants, Draining Turnover

Staff turnover has reached unsustainable levels in the skilled nursing sector, with some staff – particularly certified nursing assistants (CNAs) – leaving faster than they can be replaced.

And it goes beyond just raising wages.

Despite a 7.13% national hourly wage increase for CNAs in 2021, turnover still increased significantly at the position — jumping to 59.95% compared to 39.38% in 2020.

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Finding ways to keep CNAs in place and fulfilled for the long-term will be key to building a better skilled nursing workforce for the future.

Promoting from within is one way some of the best skilled nursing operators have been able to separate themselves at a time when most of the industry is dealing with similar staffing challenges, according to Activated Insights CEO Dr. Jacquelyn Kung.

“We want to be hiring people and growing them,” Kung said during a panel discussion last week during the Skilled Nursing News Staffing Summit. “As an industry on average 15% of our roles are promoted from within. Now look at that compared to hospitals who promote almost half of their leaders from within. Same thing with hotels and retail.”

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Kung said that hotels and retail promote up to one-third of their roles from within while senior living or seniors housing is closer to 17 or 18%.

She and other thought leaders in the space spoke to how skilled nursing operators need to prioritize their CNA workforce moving forward through better communication, more flexibly and by offering training and other educational opportunities.

Kung said some of the top skilled nursing providers fill roughly 40% or more of their roles from within, which directly translates to lower turnover as employees then feel like they have a future within the organization.

“The good news is that there are things we can do about it,” Kung said. “We can stand out as employers, we can emphasize purpose and we can promote from within at much higher rates because the best in our industry do.”

More CEOs and higher level leaders in nursing homes need to be thinking and talking about promoting from within, as that will translate to a “huge drop” in employee turnover and a “big increase in engagement,” she said during the panel.

In fact, employee engagement isn’t just about what a community or organization’s mission statement is, according to Charles Turner, chief executive of digital labor marketplace Kare.

Turner said there are some “misconceptions” around the energy and emphasis operators put around their culture. Company culture means more than just a common set of beliefs, processes and rituals and just because a company “has a better culture” doesn’t mean that is the facility an applicant will automatically choose.

“Mission statements are fun, but that’s not going to drive that next caregiver to come work for you,” Turner said.

Workforce trends are very clear, Kung added, with skilled nursing facilities getting fewer applicants and lagging in employee engagement compared to other sectors.

While the latest employment data shows the health care sector grew by 28,000 jobs in May, only 1,300 of those were nursing home jobs, according to the Bureau of Labor Statistics (BLS).

Making the CNA role a viable long-term career path

Part of the problem with retention in the SNF industry, at least for Lori Porter, co-founder and CEO of the National Association of Health Care Assistants (NAHCA) , is that being a CNA is no longer seen as a viable long-term career path.

Porter pointed to research conducted by NAHCA that found that only 6% of CNAs want to be nurses, whereas 34% are interested in being nursing home administrators — but there’s no path for that currently.

Providing additional training and opportunities for specialization in frontline care roles is one way to attack the issue.

In fact, CNAs wanting to stay “caregivers” is one reason why Activated Insights started an apprenticeship program with a large provider in the Midwest.

“For every certification that you earn, you get paid 25 cents to $1 more [per hour] and it can happen as quickly as every six months,” Kung said.

The senior care provider has reportedly built out a suite of at least five of these apprenticeship programs through which they have enabled their CNAs to advance while also offering other incentives like tuition reimbursement, according to Kung.

“It’s called skilled nursing for a reason,” Porter said. “You have to have skills and those skills have to be trained.”

It’s not just about offering more educational and training opportunities to help CNAs and other frontline staff grow, however. Making it easier to get new hires in the door will also be critical, especially with the temporary nurse aide (TNA) waiver now over.

The waiver allowed certified nursing assistant trainees, or TNAs, to work as caregivers longer than the federally mandated four months before taking a state exam. If hired after June 7, TNAs will have four months from their hiring date to meet testing requirements, CMS has said.

“The temporary nursing program and the ability to get workforce and to drive that workforce of facilities quickly was exponentially successful from an operator’s perspective,” Jalene Carpenter, president and CEO of the Nebraska Health Care Association, said. “Our members are saying that that’s what we need more of. We need to find ways to not burden somebody but to get them in and get them hands on training.”

Surveys are another tool providers have used to solicit feedback, gauge responses and get turnover down.

Getting the message across

Better communication may be one of the most tangible ways skilled nursing operators can improve retention within their company.

“You cannot engage with your staff if you cannot communicate with your staff and too many facilities are still relying on bulletin board communications,” Porter said.

There are still facilities that don’t collect CNA email addresses, according to Porter, and a lack of consistent engagement is one of the “fundamental reasons” those frontline employees feel disrespected.

“I would highly urge any facility to utilize that or any communication tool necessary, an app or whatever, to be able to have that level of communication because that’s where engagement starts,” Porter added.

Kung also advocated for operators to utilize text messages more with their staff.

“The number of text messages that are read and communicated back was between 40 and 70% of the people that received them and that’s much higher than email which is usually in the 10 to 20% range,” she said.

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