We have all read the gloomy articles regarding the critical shortage of professional care staff generally and, more specifically, its impact on care staffing for the elderly. There are numerous reasons for this shortage, some of which are controllable and others which are not. The reasons for this crisis are simple to recognize but the solutions may not be.
What is Causing the Shortage?
The large number of baby-boomers who now require and will require health care services, coupled with a declining birth rate in the United States has created an increased need for more care professionals. Additionally, many baby-boomers who are themselves professional care providers are quickly anticipating retirement. In a recent AMN Healthcare survey, 73% of baby-boomer aged nurses plan to retire in the next three or fewer years. An increasing number of younger care providers view elderly care as an undesirable or unrewarding career path. These figures are compounded by the fact, as indicated in the same survey, that approximately 20% of all “new” nurses plan to leave the profession within a year of entering the workforce.
Care provision for the elderly is a challenging task, both physically and emotionally and with compensation approximately 20% less than their colleagues in acute care, burnout and turnover rates are extremely high. On top of this, antiquated, traditional care environments serve to lower staff morale and job satisfaction. These factors are exacerbated in rural areas where the labor pool is smaller, wages are significantly lower and built environments tend to be outdated and more institutional.
While low staff wages might be thought to be an overriding factor causing competent staff to migrate away from elderly care professions, there are other contributory issues. These might include long hours, mandatory overtime, overbearing supervisors, lack of task variety and an unpleasant environment that detracts the care provider from doing their job well.
The illusive US immigration policies are increasingly impacting the availability of all levels of caregivers. According to Paraprofessional Healthcare Institute, 25% of the current direct care workforce consists of immigrants. An immigration policy that reduces the ability of qualified care professionals to enter the country could contribute to a greater shortage of staff. Many of the immigrants to this country arrive from locations where the current demographic has a higher birthrate and higher percentage of younger workforce. But these countries may also have a larger, under or unemployed labor pool and a diminishing employment outlook. Utilization of this resource may serve to help alleviate the elderly care staffing shortage.
The Impact of the Care Staffing Shortage
The overall shortage of care staff can have profound ramifications. The quality and availability of professional staff is increasing and will continue to increase the cost and competitiveness of elderly care.
In a study completed by myCNAjobs.com in conjunction with HealthcareResearch.org, that while 36% of respondents indicated they were making more money, 46% indicated they were receiving more job offers and, on average, the respondents were receiving at least 3 calls per week for other jobs than they were currently in. Even with the increases in salaries and wages indicated by the respondents, 40% indicated that they cannot earn enough to remain in the profession and 64% said they are always looking for another job. And the conundrum for care providers is that staff feel that reputation in the market place, which can be marred by heavy staff turnover, is critical to their desire to work for that provider.
There will also be a significant change in the care offering provisions to which people have become accustomed. Long-term skilled nursing is becoming, and will continue to become, a care and housing option few elderly choose. Providers will face diminished workforce availability, lower staffing levels and tighter profit levels resulting in the need for staff to focus on volume of care rather than quality of care. Those who are searching for care settings may begin to focus more on how the provider integrates professional with familial care strategies in a more “home-like” environment to accomplish what was once viewed as the sole purview of the professional. The portion of care that nuclear families have provided may morph into care provided by a wider extension of family members and in direct collaboration with the professional.
Providers are faced with a problem that is produced by diminishing returns and payor reimbursements and the need to attract competent staff with competitive pay rates and benefits. It is no surprise that many skilled nursing providers are closing their doors or creatively converting their environments to alternative uses such as independent living apartments, assisted living apartments or, as was recently done at an Iowa location, public school classrooms.
To compensate, providers are hiring “agency” staff, usually at a higher cost, and often, hiring less experienced staff. These approaches may result in diminished quality of care and, quite often, a higher cost of service due to increased liability costs. Additionally, while these professional temporary staff can serve to fill the staffing gap, the trade-off is a revolving door of caregivers who may not be fully invested in resident quality of life or resident care.
Solutions that may Help
There are fundamentally two approaches to the attraction and retention of competent and caring staff. The first is the creation of a rewarding and empowering employment philosophy. The second is providing a safe and comfortable workplace designed for staff efficiency as well as resident comfort, keeping in mind that this environment is the residents’ home.
Any employment culture should include empowerment of employees in order to achieve both personal and professional goals. Creating a culture that celebrates the workforce and rewards performance in both tangible and intangible ways are important to staff satisfaction and retention. This approach must begin at the very top of the organizational chart. Respecting staff at all levels from CEO to night shift janitor is a proven approach to staff satisfaction. With praise, an employee will feel their importance as a part of the organization and will be invested in the success of the provider. Rewards beyond simple praise can also be effective and can include such things as an extra paid vacation day, discounted gym memberships, tuition assistance, child daycare scholarships, and “finder’s fees” for new hire recommendations. The list is only limited by one’s imagination.
Of course, financial rewards are also a method of employee retention and satisfaction. These should not be arbitrary nor only based on seniority or longevity. Employee goals should be discussed and dedicated to writing within the context of periodic and regular employee reviews. Helping to achieve those goals, as well as the quality of employee work product, can be discussed and benchmarked during those reviews.
Combined with a conscious and progressive staffing approach, the built environment can not only provide a more efficient workplace but also a more home-like environment for the residents. Together these attributes serve to increase quality of care and quality of care staff.
While new, small-house models of care have emerged as resident-oriented responses to more institutional and medical environments, designers must understand how these models can also serve to elevate staffing and care efficiency. Distances to resident rooms can be reduced through the use of provider “touch down” stations or wall mounted tablets for quick electronic record input. Plan layouts that covertly bring staff and residents together will not only increase interaction, but allow ongoing, up-to-date staff knowledge of resident needs.
In the design of new or replacement environments a logical inclusion is spaces where family members can locate, either for short periods or longer lengths of time. If family members participate in care for residents, it not only helps (but does not replace) the burden of care for the professional provider. Additionally, closely examining operational issues during the design process can significantly impact staffing efficiency. Walking distances for staff to attend to residents, the sequence of food delivery and strategic location of decentralized resident medical and pharmaceutical supplies can easily be overlooked during the design process, but can make profound differences in operational efficiencies, particularly when each task is multiplied over the life of the building. Planning and design common sense combined with an understanding of how a care environment operates can be one solution that addresses staffing shortages.
One of the most important aspects of environmental design that can improve staff efficiency and, in many ways, contribute to workplace satisfaction, is technology. The majority of current and future care staff have grown-up immersed in technology and recognize it as an aspect that improves their lives. Technology can relieve some of the drudgery often associated with care provision. Electronic health records provide a faster and more accurate method of inputting resident efficacies and, additionally, frees up time for staff to interact and become more familiar with each resident.
Technology is particularly important to those who reside in rural areas. Tele-medicine, particularly for non-emergency health reviews, can alleviate the need for senior level care staff to be on site. This can help reduce care staff spending time preparing and accompanying residents during transfers to doctors’ offices or hospitals.
In today’s market, senior care operators need to be nimble and creative to attract and retain quality staff who can help maintain the market competitiveness and financial sustainability of the provider. There is clearly a relationship between the quality of the built environment and its designed components, the culture of the provider, the quality of staff within that environment and ultimately staff and resident satisfaction. Good designers fully understand this and use their expertise to help clients successfully navigate through the process.
Jeffrey Anderzhon, FAIA, NCARB