Finding and Keeping Staff

November-December 2001


Mr. Dawson is president and Ms. Rico is vice president, Paraprofessional Healthcare Institute, Bronx, NY; Julie Trocchio is director of Long-Term Care, Catholic Health Association, St. Louis.

The "Employer of Choice" Strategy Can Give Those Who Adopt It an Advantage over Competitors

Those responsible for recruiting, training, or supervising direct-care workers in long-term care (LTC) organizations hold one of the most challenging jobs in health care today. That is because direct-care workers — certified nurse aides (CNAs), home health aides, personal care attendants, and others — are increasingly hard to find. Once found, they are increasingly hard to keep. Staff vacancies make a supervisor's job especially difficult because "working short" increases the stress on all those who do remain on the job.

Why have direct-care workers become such a scarce resource? The answer can be seen in a glance at recent history. In the last quarter of the 20th century, the number of American women between the ages of 25 and 44 who were available for entry-level work nearly tripled-from just over 10 million in 1968 to 30 million in 1998.1 However, as the "baby boom" generation hit middle age in the late '90s, this trend began to level off. The U.S. Department of Labor predicts that, by 2008, the number of young women available for such work will drop by 1.4 percent. The percentage is not large, but the simple fact that the number is shrinking rather than growing is ominous for long-term care.

No wonder that staffing vacancies are spreading in LTC facilities and home care agencies across the country. In the past year, more than 40 states have enacted legislation or created task forces in response to the staffing crisis.2 Meanwhile, the demand for LTC services is sure to increase dramatically because the nation's population is aging. When we add an aging population to this fundamental change in the entry-level labor supply, we are forced to recognize that the emerging "care gap" between the demand for and supply of entry-level workers is a long-term, structural problem. We have entered an entirely new era, one in which the labor supply, already scarce, will become an increasingly competitive resource.

Fortunately, Catholic health care organizations are in an advantageous position in this respect because they have a unique perspective on staffing, shaped by four fundamental values. Catholic institutions:

  • Respect the dignity of all persons, including staff members
  • Have a preferential concern for the poor, including poor people who become direct-care workers in long-term care
  • Seek to promote the common good, which includes adequate wages and benefits
  • Believe that justice requires them to be in "right relationship" with their workers through a healthy and life-giving work environment3

Knowing they have this advantage, Catholic LTC providers can begin to plot a strategy that combines their mission and business needs and strengthens both. The Catholic Church has always placed special emphasis on both the needs of low-income people and the dignity of labor.4 An organization that sees recruiting and retaining staff as not a chore but an opportunity to fulfill its ministry can both build a stable workforce and maintain a high level of care.

Achieving this goal will require a long-term vision, one focusing on both the resident and the caregiver. Both are human beings; true care cannot occur unless a stable relationship — clinical, material, and spiritual — is forged between them. To create this relationship, a LTC facility must first become an "employer of choice" facility: one that improves care quality by improving the quality and stability of direct-care jobs. In the process, such a facility will improve the public image of long-term care among both residents and their families, on one hand, and job seekers, on the other. Specific tactics for implementing an employer-of-choice initiative will vary from facility to facility, but any LTC facility will, by adhering to the following five principles, demonstrate a deep and abiding commitment to the well-being of its staff.

Recognize Caregiving as a Vocation
Most people are drawn to LTC work by a desire to help. They remain in the field because they gain tremendous satisfaction from their relationships with residents. Facilities that value this commitment and respect strong resident-caregiver bonds will greatly increase job satisfaction — and, as a result, staff retention. To build a supportive job culture, facilities should:

  • Provide direct-care workers with consistent assignments that respect the personal connections between them and residents.
  • Include direct-care workers in management team meetings; solicit their input in care planning.
  • Celebrate the deep spiritual and personal calling shared by most caregivers. Provide opportunities for retreat and renewal that build a sense of community and emphasize the meaningful nature of LTC work. Use this sense of shared calling to fashion connections between direct-care workers and the nursing staff.
  • Seek, in job candidates, personal values and experiences that demonstrate a caring nature. The best indicator that a recruit will stay in the field is personal caregiving experience with a family member or other loved one.

One organization that understands direct care as a vocation is the Carmelite Sisters of the Aged and Infirm, based in Germantown, NY. Every year, the congregation hosts a conference for direct-care workers from its 23 U.S. LTC facilities.* Approximately 100 CNAs and food service and housekeeping workers gather for a two-day meeting that emphasizes the spiritual nature of each task they perform. The participants, who typically come from a variety of faiths, are invited to attend a eucharistic celebration and a special prayer service, including a "Blessing of Hands Ceremony," that serves as a sign of their dedication to work with the aged and infirm.

Recognize the Need for Both Decent Compensation and Ongoing Personal Development
LTC leaders should ensure that workers receive wages and benefits enabling them to provide for their families. Aside from being just, such compensation lends stability to workers' lives at home, a factor crucial to their ability to deliver consistently high-quality care in the workplace. In addition, LTC leaders should:

  • Use "learner-centered" training techniques in every aspect of training — entry level, new employee orientation, in-service programs, and supervisory training (see below).
  • Recognize that communication and problem solving skills are critical for direct-care jobs, and that these skills can be learned. Develop an internal training program that, moving beyond clinical and personal skills, helps entry-level workers identify problems, create solutions, and communicate appropriately with both residents and other care team members.
  • Value "incidents" as opportunities, not to punish or reprimand workers, but to reinforce their problem-solving skills.
  • Use a "job coach" to intervene in difficult situations, helping the worker involved to identify the issues and to work on behavior changes before dismissal becomes the sole remaining option. Train all employees (including those in administration, operations, and patient services) in coaching methodology and practice, thereby ensuring a uniform approach in the application and enforcement of workplace policies. Doing so can create a fundamental shift in a facility's work culture (see below).

Support Workers in Personal Emergencies
Any person's work can be negatively affected by problems occurring off the job. Low-wage workers may especially need supportive services provided by their employers. LTC leaders should see to it that such services are available for both new and long-standing employees.

In fact, the facility should provide either an on-site counselor or counseling services from a community-based agency. In either case, the facility should make sure that the counselor is positioned to connect workers to a broad range of supports that can help stabilize their personal lives and thus improve job performance (see below).

At Cooperative Home Care Associates (CHCA), Bronx, NY, one experienced aide began calling in with various excuses for missing work.* Fed up, her supervisors had decided to fire her. However, they first asked the company's on-site counselor to investigate the situation. The counselor found that the aide suffered from menopausal depression and could not afford the medication prescribed for it. The aide was placed on a leave of absence and referred to a private mental heath organization, which, enrolling her in Medicaid, helped her work through her depression. After recovering, the aide returned to CHCA, where she remains today.

Identify and Change Organizational Practices That Devalue Direct-Care Staff
Nursing schools, like most medical institutions, tend to reinforce a hierarchical view of power. Moreover, nurses, whether registered nurses (RNs) or licensed practical nurses (LPNs), are usually not taught the supervisory skills needed to manage a large staff of CNAs or home health aides. And, in facilities facing staffing shortages, even the best-intentioned supervisor is often overwhelmed by the sheer volume of critical issues. As a result, supervisors sometimes say and do things that devalue direct-care staff.

Some of this stress can be relieved by changing the job structure of direct-care workers. Just as important, however, is changing the way nurses work with, and supervise, direct-care workers. To this end, LTC organizations should:

  • Invest time and money in improving the supervisory skills of RNs and LPNs (including both nursing supervisors and charge nurses).
  • Train supervisors to use a supportive, problem-solving approach to supervision ("coaching") instead of one that focuses exclusively on enforcing discipline.
  • Form nurses and direct-caregivers into care teams, thereby emphasizing the importance of direct-care services, building a sense of community, and ensuring that direct-care workers have a voice in matters that affect their work lives.
  • Reinforce community by emphasizing the spiritual nature of caregiving and the deep personal commitment all individuals can bring to this work.

Institutionalize the Initiative
An organization striving to become an "employer of choice" should establish a permanent staff committee to gather information, make suggestions, and monitor program success. Such a committee, containing nurse supervisors and administrative and operations personnel, should have direct-care workers at its core. The new committee will:

  • Define the problems and barriers facing frontline workers.
  • Set and communicate goals and objectives.
  • Implement changes slowly and in stages, in a manner likely to build support throughout the organization.
  • Create performance benchmarks and regular management reports on each aspect of the initiative, thus enabling the organization to continually evaluate progress, celebrate successes, and identify new opportunities for innovation. Key performance measures will include reduced turnover among direct-care workers, increased retention among new employees in particular, and improved attendance and reduced tardiness among employees in general.

Last year, Alexian Brothers Sherbrooke Village, a skilled nursing and assisted living facility in St. Louis, established a recruitment and retention program that virtually eliminated the temporary staffing that had been costing the facility as much as $50,000 a month. Called the "One Great Unit Program," the initiative successfully brought CNAs into the recruitment process. The program:

  • Encouraged CNAs and other entry-level workers to help identify problems and propose solutions
  • Placed CNAs on the team that interviews potential new employees
  • Gave $250 bonuses to staff who successfully recruited new employees (the bonuses were paid in increments as the new workers reached first 30 days, then 60 days, and finally 90 days of employment)
  • Presented modest prizes to those workers who had perfect attendance in each two-week pay period

The Elementary Question
Many LTC facilities and home care agencies are experiencing painful direct-care staffing shortages these days. Although they may seem to differ from facility to facility, these staffing problems will usually improve once the leaders of a facility facing such a shortage implement three simple steps:

  • Improve direct-care jobs.
  • Recognize and reward direct-care workers.
  • Build support mechanisms for direct-care workers.


  1. The 1968 figure is from the U.S. Bureau of Labor Statistics. Other data are from Howard N. Fullerton, Jr., "Labor Force Projections to 2008: Steady Growth and Change in Composition," Monthly Labor Review, November 1999.
  2. North Carolina Division of Family Services, "Comparing State Efforts to Address the Recruitment and Retention of Nurse Aide Workers," Raleigh, NC, September 1999.
  3. Ethical and Religious Directives for Catholic Health Care Services, U.S. Conference of Catholic Bishops, Washington, DC, 2001, pp. 10-11.
  4. See John Paul II, "Laborem Exercens," Origins, September 24, 1981, pp. 225, 227-244.

What is "Learner-Centered Education"?

Learner-centered education is based on an understanding of the particular way adults learn. All people are capable of learning, regardless of age. Although adults often resist "education," they incorporate new knowledge throughout their lives.

Adults tend to absorb and integrate new information most effectively when they are engaged in the learning process. For this reason, we recommend using problem-based learning techniques. Rather than "providing information" to passive learners through lectures and demonstrations, instructors facilitate learning by building on what traininees already know, engaging them in critical thinking, and making the trainee's job "come alive" through role play and other activities that relate the training to the actual needs of the job.

— Steven L. Dawson and Christine Rico

Coaches And Counselors

A job coach works with an organization's employees to identify and change attitudes and behaviors that cause poor job performance. The coach does this by helping employees understand appropriate workplace behaviors and learn problem-solving skills. Typically, an employee exhibiting inappropriate behavior is referred to a coach (who may or may not be the worker's direct supervisor). The coach first sets clear expectations for job performance and, second, helps the employee resolve issues that keep him or her from matching those expectations.

A counselor, on the other hand, provides troubled employees with a friendly ear and refers them to such supportive services as subsidies for child care or emergency housing assistance. Counselors focus on helping employees deal with external problems affecting work, whereas job coaches help them with internal problems.

— Steven L. Dawson and Christine Rico

"Employer Of Choice" Resources

Many Catholic health care systems and facilities already incorporate some elements of the "Employer of Choice" model in their employee recruitment and retention programs. However, an organization planning an initiative intended to change its entire workplace culture will require significant expertise, information, and resources.

It is best not to travel into such challenging territory alone. Organizations planning such a project should consider partnering with organizations skilled in dealing with issues involving low-income workers. Two such organizations are:

Catholic Charities USA. Catholic Charities is the nation's largest private social services network. Its 1,400 local agencies and institutions annually serve more than 10 million people in need, regardless of religious, ethnic, racial, or social background. Local Catholic Charities agencies can facilitate "employer of choice" programs by helping LTC facilities recruit new workers and provide them with support services. To find a local Catholic Charities agency look in your local phone book.

The Catholic Health Association (CHA). CHA, in partnership with the Paraprofessional Healthcare Institute, is developing an Employer of Choice Strategy Guide, to be published in summer 2002. For information about it, contact CHA's Julie Trocchio, Suite 1000, 1875 Eye Street, NW, Washington, D.C. 20006; telephone: 202-721-6320.

— Steven L. Dawson and Christine Rico


Copyright © 2001 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Finding and Keeping Staff

Copyright © 2001 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.