Maria knows all of her residents' names. She knows what they like to eat, what calms them, what their families expect. She has deep and meaningful bonds with the people she cares for and strives for quality not because it is a mandate, but because she truly cares for the people in her charge. She has woken at 3 a.m. worrying about how a resident is doing and she calls to check in on her off hours.

Maria's dedication and hard work, her patience, and the intelligence and understanding she applies to her everyday work are the most fundamental elements of quality care.

But Maria makes minimum wage. After she finishes her day as a CNA in a long-term care facility, she goes to her second fulltime job, but still struggles to make ends meet. She has no medical coverage. She is a single mom with a high school education, struggling to pay for daycare and balance her work and family.

As a direct care worker, Maria has dedicated herself to a job that is profoundly demanding and exhausting. She loves the work and doesn't want to leave her residents in less capable hands. But when she learns of a job opening at a local grocery store that pays more, offers health insurance and lets her cut down on her second job to make time for her children, the choice is clear.

Maria is not a real CNA, but her story mirrors that of the 70 to 100 percent of direct care workers who leave the field every year. That turnover spells big trouble for quality, costs and operations, and the Better Jobs Better Care program (see sidebar) set out to do something about it.

Through eight research and five demonstration projects, BJBC found some simple, and low-cost, answers to the industry's complex staffing problems.

TURNING THE TIDE

One of the surprising findings was that it doesn't take a lot of money to see a lot of improvement.

Sandy Spillman, PhD, COO, Salem Senior Housing, Winston-Salem, N.C., and a BJBC provider, saw turnover at just one of her facilities drop from 62 percent to 8 percent, and it didn't cost a cent. "I didn't get an extra pot of money to work with. The money's not coming from anywhere: It's the same money you have, it's just distributed differently. Overtime is cut down because you have a better team and you're not paying for new criminal checks and retraining people."

She's not alone. Linda Barbarotta, senior communications associate of Better Jobs Better Care, points to Birchwood Terrace Healthcare in Burlington, Vt., a BJBC participant that was facing high turnover of its direct care staff and using a significant portion of its staffing budget to pay for agency staff, sign-on bonuses, last-minute assignment bonuses, and paying staff who worked two 12-hour shifts for 30 hours. In essence, the facility was paying the costs of turnover at the expense of investing in permanent staff, she says.

BJBC Vermont hired consultants to work with the administrator, Scott West, to address the staffing situation. West was able to stabilize his staffing by increasing his permanent full-time and part-time staff. As his retention increased, the costs of agency use and constant new employee training plummeted. As a result, he was able to raise wages simply by spending money more wisely, but not adding any.

WAGE CONCERNS

Addressing wages is essential to retaining employees who are barely making ends meet on the average CNA salary. "Many CNAs need to have two jobs if they're going to survive and have a life," says Dr. Spillman, who is also executive director of the Direct Care Workers Association in North Carolina.

And while many workers find the job rewarding, it can also be demanding and physically and emotionally strenuous, making it difficult to get to their second jobs.

But it's a financial necessity when many facilities are only paying minimum wage, adds Linda Buehler, a CNA at Parkhouse Providence Pointe, Royersford, Pa., and a member of the facility's direct care workers' support team. Buehler talks to CNAs all over the country through her involvement with the Pennsylvania Better Jobs Better Care program.

Even those who are making more than minimum wage are not in the clear. "We're making less than road flaggers," says Skip McDonald, CNA, another member of the support group at Parkhouse, a BJBC facility that is on the higher end of the pay scale.

North Carolina also pays above minimum wage, with an average hourly rate of $8 to $8.63, but that's still often far from enough, particularly for the many single mothers in the field, Dr. Spillman says. Further, many direct care workers have little to no insurance, or can't afford high premiums and deductibles.

Interestingly, most of the direct care workers that we spoke with for this article were quick to point out that they do not do their jobs for the money?that caring for people is more important than what they make. They are quick to downplay the importance of low wages, fearing that they'll be seen as greedy or ill motivated. But low wages are a problem that must be addressed.

"Balancing the complexities of work and family responsibilities without money for daycare, health care and transportation often overwhelms even the best-intentioned workers," reports Ingrid McDonald in the BJBC issue brief, Respectful Relationships: The Heart of Better Jobs Better Care.1

UNDERSTANDING STAFF NEEDS

But wages are only part of the turnover problem. A lack of fundamental respect and understanding from supervisors, residents and even coworkers is a common lament among direct care workers. Understanding the challenges your direct care workers face and putting the time in to create a respectful workplace can go a long way in improving retention.

Dr. Spillman tells of an administrator in one of her facilities who had a 62 percent turnover rate and a reputation as "the firing queen." If an employee was repeatedly late, the administrator assumed she was irresponsible or uncommitted and fired her. But BJBC helped her see that there was more to the story.

A coaching training company that was working with BJBC taught the administrator how to approach problems in more productive ways. The company encouraged "the firing queen" to replace the statement "I've written you up three times and you're out," with, "You're good when you are here, what can I do to help you?'"

She learned that, in many cases, employees were late because they were rushing from their other jobs and were doing all they could to make difficult schedules work. So instead of firing those employees, she stepped in to try to help them. In one instance, an employee worked for a home care agency before coming to work at the ALF. Because home care schedules are a bit more flexible than facility ones, the administrator called the HHA to see if they could work together to get the employee to work on time.

The "firing queen" now has a turnover rate of 8 percent. "Now that's impressive," Dr. Spillman proclaims.

"You have to trust your employees," says Buehler, and understand that they are trying to balance their lives. At Parkhouse, an onsite daycare center is one way to help staff balance work and childcare arrangements. Several direct care workers also have parents in the facility, so they can check on them throughout the day. One employee told us how she arrives at Parkhouse early so she can spend some time with her mom. She checks in on her lunch break and gets her settled before leaving work for the day. Not only does this ease her stress, but it makes her committed to her job because it provides her with balance.

Parkhouse also addresses transportation issues by offering bussing for employees. And during a particularly bad snowstorm, the facility sent out snowmobiles to get employees who were willing to work but unable to make it in.

That's not to say you can't fire anyone. "Some people don't need to be in this business," Dr. Spillman says. But if you can make a few adjustments or calls to keep the good ones, you'll have higher quality, more consistent care and lower staffing costs.

IMPROVING SUPERVISION

Besides meeting employees' needs, look for ways to improve supervisory relationships in general. A positive and respectful relationship plays a powerful role in employee satisfaction and retention.¹

Several years ago, when turnover was an ongoing issue at Cedars Sinai Park, a continuum of care campus in Portland, Ore., management looked for the source.

"We recognized that frequently workers do not leave long-term care employers in general; they leave their supervisors," says David Fuks, MSW, CEO of the facility, which was one of the eight sites involved in BJBC's Oregon Demonstration Project, Oregon Works!

A large part of the problem is that many supervisors are ill prepared for the position. "Supervision, particularly at the line level, is being done by nurses, and nursing schools don't necessarily train people to be supervisors; they train them to be clinicians," Fuks says.

To address this, BJBC in Oregon contracted with LEAP to provide training to the eight BJBC provider sites, including Cedars Sinai. LEAP (an acronym for the program goals of learn, empower, achieve, produce) is a workforce development program that focuses on empowering staff and enhancing staff-resident relationships via the person-centered care model. The program teaches nurse managers, staff nurses and CNAs how to build positive relationships with residents and families, foster capable work teams, develop effective communication techniques, feel valued and effective, and release "hidden" talents.²

Developed by Life Services Network of Illinois and Mather Lifeways, LEAP shows great promise towards reducing turnover.² Fuks has seen this firsthand at Cedars Sinai.

"The more effective supervision is making a difference. Our turnover rate at the front line level has gone down," he says.