As those in the industry continue to adapt amid a historic workforce shortage and higher acuity patients, nursing staff are having to adapt in new ways.
All nursing levels, and even dietary and housekeeping staff, need to work together to ensure a facility is providing the best patient care, despite the employee scarcity felt across the industry, Ja’Nay Crippen-Derry told Skilled Nursing News.
Crippen-Derry, VP of clinical services at CHI Living Communities, along with Lifespark VP of Operations Amanda Johnson, spoke about the transformation of the clinical team during SNN’s CLINICAL conference last week.
“You can’t just think of the clinical team as being RNs, LPNs, and CNAs. It really is everybody, we have to engage everybody in providing the best care,” said Johnson. “That includes social services, community life, wellness, recreational therapy, down to our ancillary services, housekeeping, laundry. Everyone is part of that person’s care plan, and how do we engage them in every aspect of a person’s care?”

Added roles, resources to mitigate risk
Higher acuity among skilled nursing residents has meant care teams have had to shoulder more risk among the clinical team, while adding value-based positions like the life care manager at Lifespark.
This life care manager role is very person focused, and its purpose is to inform the clinical team of any other ancillary services a resident might be receiving, Johnson explained. The position also ensures the team is meeting regulatory requirements, keeping up with the care plan and care conferences and other factors that could detract from staff time.
“It’s a way to leverage and support the teams without necessarily changing what you’re doing,” said Johnson. “[We’re] creating an environment where people can thrive as they live there and have strength and purpose, and also our employees see that, the caregivers can see that and want to be in our profession.”
It helps to be part of a larger healthcare system too when mitigating risk amid rising acuity, added Crippen-Derry. CHI is the senior living division of nonprofit Chicago-based system CommonSpirit Health.
Being part of CommonSpirit allows CHI access to analytics, quality and legal teams. And, clinical teams have a voice when discussing patient experience and patient care.
“All of those in acute care can come together as one to either fix an issue or come up with solutions to barriers or to improve our quality of care … CommonSpirit is great about including all service levels in what you do every single day,” said Crippen-Derry.
Still, there can be improvement at the top, she said, especially when it comes to support for the administrator – a role recently associated with high burnout and difficulty in replacement. In SNF organizations this role has quickly become a market leader, a culture specialist and central to culture satisfaction among employees – and something catered to younger leaders However, the pandemic posed problems for young leadership to emerge.
“Young leaders have so much put on them. And unfortunately, the ones who started during the pandemic, in particular, didn’t learn how to really be a leader. They learned how to react to everything that changed every second of the day,” added Johnson.
While it’s no secret that long-term care professionals can pivot faster than any other profession, she said, administrators and other SNF leaders need to find their strengths, and operators need to give them space to cultivate these strengths and use them to build culture.
LPNs, RNs, CNAs
In terms of the core positions of the clinical team – licensed practical nurses (LPNs), registered nurses (RNs) and certified nurse aides (CNAs) – Johnson said the industry needs to empower clinicians to do what they do best, instead of being preoccupied with licensures. Also, regulation needs to ease up, leaders said.
It comes down to having some flexibility with regulatory issues to ensure value on both ends.
“I remember when I started in [long-term care], the LPNs ran the nursing homes. We didn’t have a lot of RNs that were really in the profession. They were very much in the leadership roles, and LPNs did everything,” said Johnson. “I think we’ve made it harder.”
Crippen-Derry agreed that LPNs are coming to the forefront in leadership roles and essentially “run” the nursing home. But, state bureaucracy has gotten in the way. Regulatory bodies need to be more open to LPN leadership, she said.
“CHI in one state ran into some issues where the Labor Board does not allow them to be on salary and be on call. We had to revamp our structures in that state,” noted Crippen-Derry. “We also have to ensure that if you are going to allow LPNs to be [leaders] that we train them to do so effectively, and then offer support during the time where they are taking on leadership roles.”
While LPNs can expand into leadership roles, CNAs can take on more responsibilities too, especially with tasks usually assigned to an RB or LPNs like passing out medication to residents, Johnson said.
Johnson would like to see more med pass programs available to CNAs that allow them to pass medication.
CHI has tasked Crippen-Derry with creating a program in Ohio to train medication technicians in-house and in time free up CNAs to provide more care at the bedside instead of worrying about passing out medications to residents.
“We’re going to have more people to take care of and less people to do it. It comes back to finding ways to make anything possible,” said Johnson.
Peripheral roles
Crippen-Derry and Johnson spoke briefly on some peripheral but still crucial roles – the infection preventionist and scheduler.
The infection preventionist, while part of the clinical team can’t be pulled to do something else, Crippen-Derry said. At least, that’s CHI’s practice. She said the industry can’t afford to tear the IP away from what they were originally assigned to do given CMS’ stringent stance on infection prevention and control.
The scheduler’s position “makes all the difference in the world,” Johnson said, given an increasing number of temporary and part-time staff along with a desire to work more flexible hours.
But the role is often assigned to a nurse. Learning how to properly schedule for the day is not part of nursing school, added Johnson.
“It is an art and a skill,” said Johnson. “The main nuance of being a successful scheduler is really that relationship with the people themselves, asking people, getting flexibility and really engaging [with people to] create that flexibility in a schedule without necessarily trying to. You just have people working for themselves and taking care of it,” Johnson said.
If a scheduler has a great relationship with employees, the position pays for itself, added Crippen-Derry. She agreed it’s a key component in the facility and a position HR should not remove from the clinical team.
It should be a highly compensated position and worth every penny if they’re good at it, said Johnson.
Immigrant nurses on an evolving team
Panelists also spoke about the immigrant labor pool in the SNF space as a source of alleviating staffing concerns, as well as the “huge” challenges involved.
Language barriers are the largest to overcome, Johnson said, with the industry losing “by attrition” as prospective foreign nurses can’t pass a written language test.
“Does that really qualify someone as a caregiver? We have to find ways to make those things more accessible and more sensitive, culturally sensitive to the people we’re trying to train,” said Johnson.
And, there’s no way the industry can tackle the staffing crisis with just stateside workers, Johnson said, a sentiment echoed by other SNF providers.
It really comes down to industry leaders being their own advocates to get things moving on bringing immigrant nurses from overseas, Johnson said.
However, they have a long road in convincing lawmakers, she said. As evidence, Johnson shared that Sen. Amy Klobuchar (D-Minn.), in an association meeting with SNF members, told them that there is a stack of immigration reform bills out there that “no one wants to tackle.”
And, Crippen-Derry said CHI has been working with PRS Global to bring immigrant nurses into their buildings, but recently found out that green cards for these workers have been delayed.