Compassionate Care Series

Care is at the heart of your mission and our nurses know too well the struggles of preserving a culture committed to caregivers. It isn't just about staffing—it’s about supporting. From our nurses to yours a series dedicated to compassionate care.

Dementia – A Different Type of Care Requires a Different Type of Caregiver
By BKD Director, Bob Lane
Alzheimer’s and related dementias affect millions of Americans, with Alzheimer’s disease alone impacting 5.7 million people in 2018. By 2050, this number is projected to rise to nearly 14 million, with someone in the U.S. developing the disease every 65 seconds. It’s the sixth-leading cause of death in the U.S., killing more people than breast cancer and prostate cancer combined. While deaths from heart disease have decreased 11 percent between the years 2000 and 2015, deaths attributable to Alzheimer’s disease have increased 123 percent. One in three seniors nationally will die with Alzheimer’s or another dementia.

Although many people with Alzheimer’s disease reside at home with a caregiver (family member or other), more are residing in post-acute settings such as skilled nursing centers. Fifty percent of skilled nursing center residents in 2014 had Alzheimer’s or other dementias, and 61 percent had moderate or severe cognitive impairment. Nursing home admission by age 80 is expected for 75 percent of people with Alzheimer’s, compared with only 4 percent of the general population. Persons with Alzheimer’s also have more hospitalizations, and at a higher average cost to the Medicare system. In fact, the estimated lifetime cost of care for an individual living with dementia is $341,840.

These statistics, as alarming as they may seem, are amplified when combined with the nation’s workforce issues. The nation’s skilled nursing centers are collectively dealing with challenges in recruiting and retaining quality staff, which can negatively affect care delivery. However, providers are finding ways to deliver on their commitment to quality care through improvements in organizational culture, along with innovative methods for staffing such as the neighborhood model and versatile workers.

Staff education is a critical piece to both retention and compassionate care of elders with dementia. As noted above, the percentage of people with Alzheimer’s disease as a total of the population residing in skilled nursing centers continues to increase, which requires that staff are properly trained on the disease process, its stages and the issues that can accompany the disease, e.g., agitation, problems sleeping, getting up and wandering and occasional violent outbursts. While people exhibiting these kinds of behaviors have historically been treated with antipsychotic drugs, there is increasing pressure to find more person-centered interventions that don’t require medications. These interventions require well-trained staff who are familiar with these nonpharmacological approaches and are trained in how and when to use them.

The bottom line to quality dementia care is the individual—the individual with the disease and the individual providing the care. By keeping the focus on the individual, care for those affected by Alzheimer’s disease is more likely to improve, because the staff providing the care are more knowledgeable of that person’s needs, preferences, dislikes and history.

When the focus is on the individual, compassionate care—not just minimal care—is the result. Care is at the heart of your mission and your nurses know too well the struggles of preserving a culture committed to caregivers. It isn’t just about staffing—it’s about supporting.

The Art of Hiring a Caregiver
By BKD Senior Managing Consultant, Sherri Robbins
Finding and hiring compassionate caregivers is an ongoing struggle for skilled nursing facilities (SNF). The duties of a front-line caregiver can be mentally and physically exhausting, and often for less pay than other positions within the SNF team. However, compassionate employees are a vital element to serving the diverse and sometimes challenging needs of an aging resident population. Anyone in SNF management knows you can teach individuals how to “do,” but how do you teach them to care?

Hiring is the first key to identifying and onboarding compassionate caregivers. However, it can be difficult to determine in a 30-minute interview if potential candidates will align with your SNF team and culture. To better identify applicants who are well-suited to be a caregiver, SNFs should consider implementing new and different interview methods that can provide more insight into applicants’ personalities. One suggestion might be for management to consider taking several applicants out for lunch instead of completing one-on-one interviews in the facility for a real-life example of their interpersonal skills. In addition, management could consider bringing a front-line caregiver along for the outing and allowing him or her to explain the details of the job and why your SNF is their chosen workplace. This would allow management to observe each applicant’s interactions with not only the restaurant staff but also with the current employee and the other applicants. The current employee also may be able to provide some observations of his or her own and can be involved in the creation and development of his or her own team by providing feedback to management.

Another suggestion might be to develop some out-of-the-box questions for the applicants to address during the interview process. The best interview questions will provide insight into each applicant’s skills and problem-solving abilities and whether their values align with those of your current work culture. For example, inquiring about applicants’ greatest achievements might give insight into what they value. Inquiring about what prompted applicants to apply for this position might give insight into what motivates them. Asking applicants which animal they would choose if they could be any animal could give you some insight into their perception of themselves. There certainly is no right or wrong answer with this type of question, but it can be fun and may provide different insights into the personality of potential caregivers than standard, expected interview questions. By asking something unexpected, you also may get to see how the applicants perform under pressure or how they react to surprises—which inevitably arise in the SNF setting.

The current unemployment rate is low, which often leaves a smaller pool of qualified applicants from which SNFs can draw. If not already in place, management may want to consider cultivating a social media presence and expanding its hiring practices on various platforms to identify additional qualified applicants. Partnering with local health care training facilities, such as nursing schools, also may be an option depending on geographical location. Things management may need to consider when hiring those still in pursuit of a health care degree include the necessity for more flexible scheduling, which may require alternatives to eight- or 12-hour shifts. However, thinking outside the box and striving to meet the needs of potential caregivers can lead to positive, long-term additions to the SNF team.
A final suggestion might be for managers to consider generational differences in the workplace and educate themselves, which can help develop hiring strategies that are sensitive to the different priorities, needs and desires of the diverse applicant pool. Management should strive to educate SNF team members on these generational differences to create an inclusive environment for a variety of demographics and a more seamless transition into the provider’s culture.

SNF management should take the interview process seriously and work to identify the best hire for all positions. Identifying compassionate caregivers and putting them in the “right seat on the bus” is a big step in the right direction of building a team of cohesive and talented individuals. However, hiring is only the first step in the process. Managing turnover requires an ongoing effort to motivate and maintain employees once they become a part of the SNF team.

Download our tool to try ten “out-of-the-box” interview questions.

Coaching: Your First Line of Defense in Retaining Quality Staff
By BKD Director, Bob Lane
Turnover, especially of front-line direct care staff, is a costly, disruptive issue for many health care providers. When there’s little staff continuity, care suffers. This can spiral into further issues that affect operations, including dissatisfied residents, families and other staff, regulatory citations that can sometimes result in fines and breakdowns of systems that can cause unnecessary hospital readmissions.
Many providers attempt to combat this problem by treating the symptoms. They throw good money after bad, spending thousands a month on staffing agencies to plug holes in the schedule or pay overtime to a small number of staff who repeatedly volunteer to cover shifts. While paying overtime in the short term is better than overusing agencies, this strategy can still backfire because it creates a new “norm” of income for the staff working overtime. When the vacancies are filled and overtime goes away, these staff will often quit because their income is “cut” after having been artificially inflated for a short time. They then move on to other opportunities where they can try to make up that difference.

Another strategy providers use is to pay bonuses for new employees to come on board and/or referral bonuses to existing employees. While this can be mildly effective, improper management and tracking also can cause problems similar to the overtime scenario.
The final and probably most common approach desperate providers take is to get into a wage war with other providers in their market, in essence driving up costs for the whole market.

The total cost burden for one front-line caregiver position turning over can be quite expensive—as much as $7,000 to $10,000, depending on the location. This includes the direct costs that most providers account for, such as advertising, but also the indirect costs, such as lost productivity. The problem of turnover can rapidly deplete operational funds if not addressed—download our Turnover Cost Calculator to see how your organization is doing.

So, what can providers do to combat this problem? As mentioned above, the answer lies not in treating the problem’s symptoms, but in investing the time to identify the potential root causes. One common root cause for turnover is the front-line supervisor, who is placed into a role that requires oversight of other staff’s performance while also performing one’s own job duties. Without proper education and training, these supervisors might fail to do this part of their job, allowing staff to do their own thing, which creates problems that get kicked up to the director of nursing or administrator. Alternatively, the supervisor might try to supervise but use a punitive approach that ends up driving staff away.

There’s a better way, and it’s found by equipping supervisors with coaching skills. When supervisors are properly trained, they have more confidence in daily staff oversight and likely have more time to succeed at their own job. These coaching skills include active listening, self-awareness, self-management and understanding how to properly present a performance problem to an employee. When front-line staff feel like they’re being listened to, and can participate in getting problems solved with their immediate supervisor, they have greater loyalty to the organization and higher job satisfaction. This is a great equation for improved retention, which sets the stage for improved outcomes in care, greater satisfaction of residents and families and improved regulatory performance. Operational costs also can decrease because money that was being spent on agency, overtime, etc., can be redirected to other areas that benefit residents and staff.

Cultivating a Culture of Care
By BKD Senior Managing Consultant, Sherri Robbins
Staffing turnover costs senior living providers thousands every year. A driver of turnover in the senior living industry revolves around the work required of a front-line caregiver, which is physically and mentally exhausting—and often pays less than lower-stress positions. To further complicate this issue, the current regulatory environment has caused reductions in reimbursement along with more stringent laws and regulations, making it difficult to increase compensation to motivate consistent staffing. What if the solution to all these issues lies in a cultural shift—requiring low monetary commitment—to provide a more stable, cared-for workforce?

Since satisfied employees are less likely to look for another job, successful providers are now focusing on developing a compassionate culture to better meet their employees’ needs. True compassion involves an authentic desire to help others, have a positive effect on others and ultimately elicit a positive emotional response. When we treat ourselves and others with compassion, there’s often unity that raises the group to a higher level. This is when strong bonds begin to form, trust is established and a willingness to collaborate on projects and shared visions becomes a driving force. When people work in a supportive environment or compassionate culture, they often feel safe from competition and have less fear of failure, which can result in greater resilience and lead to greater job satisfaction. Providers can begin to define their culture by identifying and clearly articulating a central purpose and set of core values. However, cultivating a culture of care goes beyond purpose and values and is truly refined through actions and words.

How can senior living management bring more compassion to the workplace and develop a culture of caring so staff members feel they’re part of something larger than their tasks and paycheck? Below are just a few ideas that could easily be implemented and begin the process of changing the actions and words that define your culture.

  • Senior living management should be an example of compassionate leadership. Leading from the heart often inspires others through kindness, flexibility, support and empowerment.
  • Senior living managers must always check the motivation behind their decisions, words and behaviors. Since every word and action generates a reaction, be sure the ripple effect you produce is positive and promotes a culture of compassion. 
  • Get to know your staff. Ask personal questions about their family and take time to talk about yourself and your family. 
  • Greet your staff members regularly and call them by name. Senior living managers should routinely be present for all three shifts. Coming in early to interact with the night shift one day a week and staying over into the evening shift one day a week will allow time to interact with employees from those shifts. It also may make you more approachable, which could lead to a more cohesive team. 
  • Encourage all employees to consistently practice conscious communication. Senior living managers should be a role model for providing feedback in a way that inspires and motivates for improvement rather than making someone feel unimportant and wrong. 
  • Routinely acknowledge employees’ strengths and positive attributes in front of others. Complimenting someone in front of others is a great way to boost morale. 
  • Cultivate an environment that encourages input from all staff members, not just department managers. 
  • Develop and/or cultivate a culture where it’s acceptable to ask for help. Asking for assistance can be difficult for some people. Managers who are present and engaged with staff can often be in positions to offer support or assistance without the staff having to ask. 
  • Organize team-building activities. Take the lead or ask for volunteers to set up team-building activities for employees. The possibilities are endless, e.g., have a monthly potluck, summer co-ed softball game, cookout, etc. The activities don’t have to be expensive; the important thing is that the staff are included, are given time to connect with one another and with management and feel they’re part of a team that cares about them. 
  • Develop some form of compassion challenge to inspire regular acts of kindness. This can be something that allows residents and family members to participate or something just for the employees. 
  • Develop an employee engagement committee that can perpetuate the compassionate culture. Senior living management shouldn’t lead this group, which should be led by a nonmanagerial employee. The committee’s purpose is to keep its finger on the pulse of the culture in the facility and alert management of concerns and issues. The committee should include all departments and shifts, and it should understand its role in developing and maintaining a compassionate culture. 

Download our Practical Guide to Implementing a Culture of Care, which includes both a management guide and an employee guide, as culture is fostered through the words and actions of all participants.

Dedicated, educated and compassionate caregivers are the backbone of every provider. Building a culture where compassion is a focus helps translate into better resident care, reduced staff turnover and a cohesive team. When employees feel they’re part of a culture that cares about them and their family, they’re less likely to leave without first speaking to their manager. With open lines of communication and a compassionate culture, building a team becomes important to everyone, not just the operator.

Contact your trusted advisor for more information on hiring and coaching compassionate caregivers.

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