Bringing Long-Term Care Staffing Back to Safe Levels

As providers compete for the same limited supply of personnel, they must be creative, industry expert says.

With the demand for bedside nurses greater than the supply, long-term care facilities must search out viable and effective ways to attract and keep nurses to provide the care their residents need, according to industry expert Reginald Hislop III.

Hislop, a healthcare executive, consultant, author, and widely recognized thought leader in healthcare, specialized healthcare, post-acute care, and health policy, spoke with HealthLeaders about how long-term care staffing can be brought back to safe levels.

This transcript has been lightly edited for length and clarity.

HealthLeaders: Overall, what is the general state of nurse staffing and long-term care facilities right now?

Reg Hislop III: If I were to use a scale of 1 to 10, with one being as bad as possible and 10 being great, we were at about a 6 prior to COVID so they were probably 5 or 4 and maybe in some cases 3. When we think about staffing, we talk about them in terms of nationalized trends, but the reality is, each market area or region is experiencing things differently—positively or negatively—to the national trends. The national trend is poor, but if you go into certain environments at certain locations—rural, for example, or inner city—it's far worse than the national trend.

So, we've got a long way to go and part of that is fighting an uphill battle in terms of the reputational issues that are in the industry, but also fighting certain trends that have been plagues to the overall healthcare industry, especially with regard to bedside clinical staffing, and that is, folks are burned out and they've retired.

The average age of registered nurses and LPNs was not very young prior to COVID, so you can imagine the number of folks who have just simply said, "I don't need to continue to do this anymore," or "I can continue to do this, but I'm going to do it differently. I'm going to step back, reduce my hours, work only premium shifts, maybe join a staffing agency that allows me to staff within the same environment that I was in, but do that at a much higher wage rate." So, we've got a whole number of moving pieces going on right now.

HL: So, how are they filling staffing gaps?

Hislop: Some just aren't, and that's frank reality. Some of our client base that operates in rural areas literally cannot find staff for particular shifts, so they are running bare minimum and, in some cases, have had to focus on reducing organic census or reducing occupancy levels to meet where staffing levels are realized or can be realized.

The primary reliance that providers are using today is one of three arrows in the quiver, none of which are all that great. One is simply wages. Pay more. Do whatever is necessary. Offer as many financial incentives as possible, whether it's sign-on bonuses, enhanced base pay, incentives for picking up shifts, higher shift differentials for tough-to-fill shifts and using any kind of financial lever they can to fill shifts. The other is to rely on outside agencies. That is precarious in some markets because some of the agencies don't have enough staff and can't attract additional staff to fill additional shifts.

The in-between is having folks work overtime, adding additional shifts, using incentives to create environments where folks can be flexible around picking up—instead of full shifts—partial shifts, doing things with two- or three-person teams to creatively address some of the key openings on certain shifts, but not filling the entire eight, 10, or 12 hours. But these are all duct-tape kinds of solutions; they're not permanent.

HL: As they're working to bring staffing to safe levels, what should they be doing to recruit nurses?

Hislop: The unfortunate thing is that it's going to be difficult to do a lot on a short-term basis. We've got a supply-and-demand problem. The demand for bedside nursing is greater than the supply of folk available. Some markets are better other markets are not, so as long as that imbalance exists … providers are battling for the same limited supply of personnel.

What providers can do is be creative. It sounds rudimentary but keep all your own staff and try to increase the amount of time that they're willing to work. See if you can take your part-timers to two-thirds time or the two-thirds time folks to full time and do that in a way that you can get maximum coverage and productivity out of your existing workforce.

The next thing you need to do is look at how you deliver different elements that are part of the staffing equation. Pay is only one element. The other elements include workplace satisfaction, support, giving folks the opportunity to team schedule, self-schedule, finding creative ways to address some of the core elements that are dragging folks away from bedside nursing and saying, "Is there a way that we can improve this? Are there ways that that we can improve the work-life balance, the quality of life internal to the organization?"

Partner with various agencies to see if there are ways to work with some of the nursing programs and schools in your market to offer opportunities for folks to complete their education and work for the provider … while addressing some of the costs of tuition, if that's feasible. Look at a variety of creative benefit options, which may be as easy as getting meals at work or partnering with daycare centers. A lot of our nursing staff are female and they have kids that need childcare options. The real issue is, in the short run, being sensitive to pay, but also to quality of life.

HL: How about retention? What should they be doing to hold on to their current nurses?

Hislop: Retention is the No. 1 element, so providers need to appreciate their staff in ways that show them, beyond just dollars, the significance of the work that they are doing. There's a lot of recognition that needs to be provided to the folks that are doing the work. That includes a number of different things.

One is identification of work that they're doing and rewarding them and recognizing them for that. It doesn't have to be huge—handing out movie tickets or gift cards. Doing appreciation events is a big thing. Talking directly to the staff and having open lines of communication, and making sure that floor-level and building-level management is being open and communicative in how they are dealing with the work-life challenges that staff may be having right now in dealing with burnout.

Make sure that you're being smart about how you're using staff and that you're sensitive to some of the issues that are out there and that you're not overburdening them. Step away from certain bad things like mandating overtime. Some will push back and say, "But if we don't do that, we won't get staff," and the answer is, yes you will.

But the word mandate is different. If you say, "We're not going to mandate … overtime. [But we] will ask, and we'll work with you to help you pick up shifts." That sets the tone of mutual respect.

The reasons I hear from nurses about why they don't work at certain places anymore, or they don't feel as if they should remain in bedside nursing are threefold. One is they're being overworked. Two is, they're not being treated with respect. Three, they are essentially being put in a position where they feel as if they don't have a whole lot of say around the compromise that might be going on with regard to patient care quality. That last one is a big one.

We need to have open dialogue and communication about what's safe and how we can help them and move some non-nursing tasks so we all can concentrate on patient safety.