This paper was created in 2009 by the AHCA Quality Improvement Committee for the purpose of sharing what nursing home leaders are doing that improves staff satisfaction in key areas. These improvements would be reflected in higher staff satisfaction survey ratings. These ratings in turn translate to improved staff retention and staff work practices and attitudes that support service excellence and a quality culture. Many of the change ideas offered here are backed by research-based evidence while other ideas have simply been effective for many of the individuals who contributed to this effort.

Often a good idea is repeated in one or more categories because of the interrelatedness of the categories

and usefulness of the idea. It is not expected that a leader would adopt all the change ideas contained

herein. However, there is evidence that high performers, those with overall high staff satisfaction, are

those that have adopted and sustained a higher number of change ideas than their lower performing

peers. As a result, all nursing home leaders would be wise to adopt additional change ideas in those specific areas identified by staff for improvement as measured by surveys of satisfaction surveys.

Certain items should be assessed and implemented only with the support of a specialist—e.g., a benefits

consultant or attorney. In these cases a note has been included to this effect. The vast majority of the

items listed do not cost money, but do require changes in leadership’s and management’s actions,

and facility practices and programs. The key to improvement is the ability to be consistent in words and

actions and to serve as a model.

What Matters Most to Nursing Home Employees?

My InnerView, Inc., is a company which conducts a high number of staff satisfaction surveys for nursing

home customers. My InnerView’s 2008 database includes responses from over 223,400 long-term care

employees nationwide. According to their analyses, the following items, prioritized in order of influence,

are the key areas for nursing home leaders to focus on to improve staff satisfaction.

1. Management cares about employees

2. Management listens to employees

3. Management helps to reduce job stress

4. Fair evaluations

5. Staff respect for residents

6. Workplace is safe

7. Supervisor cares about you as a person

Listed below are the key areas for improvement and ideas for specific ways to enhance staff perceptions

and build a committed and motivated workforce. The strategies listed are a combination of actions, practices, and programs.ing Staff Satisfaction:

Improving Staff Satisfaction: What Nursing Home Leaders Are Doing (2)

1. Demonstrating that Management Cares About Employees

Regularly share evidence-based clinical “best practices” and assist staff with the implementation

of changes in order to incorporate those practices into daily care.

Be transparent and share all data with staff—clinical outcomes, satisfaction survey results,

occupancy trends and financial results.

When a measurable outcome is not up to par, allow and encourage staff to participate in process

of finding a solution—identifying the root-cause, analyzing all the possible causes, and in

identifying solutions that have the best potential to improve the outcome.

Move towards audited patient records to collect data and measure results instead of simply to

identifying those who missed documentation.

Ensure that individual employee’s schedules are honored. Employees should be informed ahead

of time if their schedules and assignments need to be changed to meet organizational needs.

Work schedules and assignments are clear, well organized and posted well in advance.

Employees can clearly see the efforts made to fill vacant shifts and prevent understaffing.

Tip: Make sure your staffing coordinator is smart, fair and extremely organized.

Employee evaluations are conducted on, or before, their anniversary date. Employees are never

surprised by the information shared during the evaluation meeting regarding their areas for

improvement. For the most part, they feel the evaluation was fair and in many cases they feel

great after the meeting. Tip: Bring your employee master listing to every stand-up meeting

and announce upcoming employee anniversary dates.

Examine ways in which you can make health and dental insurance more affordable for

employees. One might consider richer benefits based on seniority. It is advisable to consult with

a lawyer or benefits expert before considering implementation.

Offer staff a no-interest emergency loan program. Designate a committee of their peers to review

each emergency loan application. It is advisable to consult with a lawyer or an accountant before

considering implementation.

Allow staff to cash out their vacation and/or a portion of their sick pay at any time. It is

advisable to consult with a lawyer or an accountant before considering implementation.

Have an Employee Assistance Program in place as an additional employee benefit. Offer staff

access to the EAP when you learn of struggles in their lives.

Make clear investments in employee safety. Ensure that there are enough patient lifts available,

that are in proper working condition, and that staff are trained in their use. Remember to have

this done for new staff.

Discuss employee safety at every opportunity and consistently let staff know that you care about

their wellbeing and do not want them to get hurt.

Recognize joyful events that occur in the employees’ lives and celebrate the event at the facility.

When tragedy occurs in the employees’ life—acknowledge it. Allow staff the opportunity to

determine how they can help ease their coworker’s pain.

Improving Staff Satisfaction: What Nursing Home Leaders Are Doing (3)

When residents pass away, inform the staff that were closest to the person if they were off work.

This will provide them the chance to come to the facility if they choose. Don’t let them come to

work after being off to new resident in the room without preparing them.

When residents pass away, offer condolences to the staff that were in close relationship with the

resident. Allow them time to grieve and attend the funeral or memorial service.

Recognize that positive relationships are a priority and therefore facilitate relationship-building

among all stakeholders in order to create a sense of community. Bring people together regularly

and engage them in relationship-building exercises.

Provide quality education and in-services that incorporate the principles of adult education. Offer

educational topics beyond the mandatory in-services required by state regulation. Use data to

drive your education agenda and use employees with subject matter expertise to participate in

the training.

Pilot test all changes and work out the kinks before spreading the change facility-wide. Never

burden the staff with a new policy or procedure that has not been thoroughly pilot tested.

During the rollout of any change, stand alongside the staff during the rollout of the new process

and provide responses and additional information that reflect your support.

Offer flu shots to the staff for free. Go one step further and offer the free flu shots to those in the

staff members’ household.

Praise and recognize staff in public. Counsel and coach the staff in private.

Recognize and reward both individuals and teams for achieving and sustaining quality goals.

Management staff should know and address employees by name. They should assist with daily

tasks if there is a need, and be present in the facility on nights and weekends so that staff on

these shifts have access to them.

2. Demonstrating that Management Listens to Employees:

Regularly measure and take action on staff satisfaction survey results. Share results with staff,

celebrate successes and improvements. For areas that need further improvement develop (with

staff) and share the plan of action and report back to staff on progress and completion. Consider

sending a letter to each employee summarizing the actions being taken to enhance the areas of

improvement gained from their feedback.

Consider the use of an employee newsletter and/or webpage to assist in promoting management

and staff communication.

Facilitate a process to have CNAs attend and participate in resident care conference meetings.

Formally invite the CNAs and help them prepare for the meetings by showing them important

information for them to share. Tip: Work with CNAs who are part of the interdisciplinary

team, to schedule care conferences times that will work for everyone including families.

Seek out individuals to “weigh-in” on any decision that involves them—e.g., process changes,

supplies and equipment. Invite vendors to show focus groups of staff and residents certain

products and their prices and let them choose which works best for them.

Improving Staff Satisfaction: What Nursing Home Leaders Are Doing (4)

Be honest with the staff. Don’t raise expectations and say “maybe” to suggestions that they make

that you know are unlikely to come to fruition. Professionally say, “No” and then explain why.

Under promise and over deliver.

Share the facility goals and strategic plans with the staff. Make a sincere effort to keep people

informed of the big picture and how they fit into it.

Be transparent and share all data with staff—e.g., clinical outcomes, satisfaction survey results,

occupancy trends, and financial results.

Have facility leaders adopt an open door policy but recognize that most staff will not walk into a

manager’s office unless invited. Leaders need to get out among the staff in order to maximize

their efforts to listen to the staff.

Conduct regular and frequent rounds to visit with and talk with the staff. Ask questions and be 1

100% interested in the answers. Tip: Slow down during rounds, linger, and be present.

Ask relationship building questions to show you see your staff as more than just workers and

that you want their input.

Focus on them: “How are your beautiful kids doing?” or “How is your husband doing, I heard

he was ill?” or “Do you have any kids? How old are they? What are their interests?” Tip: Write

the information down in order to remember.

Focus on the positive: “What is working well today?” Tip: Make sure to pass on the positive

response.

Positive feedback loop: “Is there anybody you are working with who has gone above and

beyond the call of duty today?” Tip: Make sure to pass on the positive response.

Quality Improvement—systems focus: “Is there anything we can do better?” or “What is

frustrating you today?” Tip: Consider the information they share is probably affecting more

than one person so bring this information to the next QI committee meeting.

Equipment and supply needs: “Do you have the tools and equipment to do your job?” Tip: act

on the information they share and always get back to them and let them know what you

did/will do to make sure they have the right equipment and supplies to do their job well.

Create consistent, formal, structured systems to receive employee insights and feedback such as

learning circles, community meetings and/or neighborhood meetings, regular employee

satisfaction surveys, and suggestion boxes. Be sure to check daily and post the suggestions and

your responses on a bulletin board next to the suggestion box.

Know one thing about each staff person that you can talk about when you meet—perhaps

something you share in common with them.

3. Demonstrating that Management Works to Reduce Stress

Decrease institutional noise pollution. Pay attention to the excessive use of the overhead paging

system and take steps to minimize its’ use. Tip: Turn the overhead paging system off for one

day and work with the staff to find a quieter way to communicate with one another.

Improving Staff Satisfaction: What Nursing Home Leaders Are Doing (5)

Make sure that there are ample supplies at hand. Nothing frustrates CNAs more than a lack of

clean linen available. During management rounds, open every linen closet door and see what’s

there. Tip: Remove barriers to access supplies such as CNAs having to ask charge nurses for

keys to open doors to supply rooms.

When a resident passes away—acknowledge it. Personally offer condolences to employees who

had a relationship with the resident. Allow the staff time to grieve and remind them of how

proud you are of the positive contribution they made to the resident’s life. Hold memorial

services and moments of silence at general staff meetings to honor those who have passed.

Tip: Develop systems to communicate with staff when a resident has passed away. Consider

calling certain staff members who were in close relationship with the resident at their home

(if it’s their day off) and letting them know when a resident has passed.

Address and take appropriate action with negative staff members that are contributing to their

co-workers’ job stress. Pay close attention to who is on-duty during unusually stressful times.

Notice the dynamics between the staff.

In order to minimize the stress caused by surprises, allow time for a report between shifts so that

CNAs and the licensed staff give updates to pave the way. Create a formal, structured, consistent

process for giving and receiving report that everyone can rely on.

Experiment with creative staffing configurations—e.g., spa aides, additional activity staff, and

ward clerks—to take stress off of nursing staff. Consider adding a concierge position at peak

times in order to serve new admissions and their families, answer call lights, make beds, deliver

nourishments, and so forth.

Expand the activity program in order to individualize programs for residents and reduce their

loneliness and boredom. Investing in activities staff allows the nursing staff to be more effective

and efficient.

Reduce shifts worked understaffed. Measure the number of shifts worked understaffed and

regularly report the percentage of shifts worked understaffed to the staff. Explain to the staff that

efforts are being made behind the scenes to prevent understaffed shifts and how they can assist.

Decrease the institutional environment. Create a home-like environment that is relaxing and

pleasant to live and work in.

Offer more dementia care training for the entire staff. Be sure to include regular and consistent

education regarding how to deal with combative and verbally abusive residents and families.

Offer wellness programs for the staff—e.g., smoking cessation classes, discount memberships to

the local health club, bring in a massage therapist to provide the staff with 15 minute massages,

change some of the vending machine items to healthy food choices.

Keep the facility sparkling clean and free of clutter.

Upgrade the employee lounge and create an area of peace, sanctuary and quiet.

Intentionally create spontaneity and laughter on the job. Surprise the staff by creating “fun” and

laughter at every opportunity. Organize a facility choir made up of staff and residents.

Create a culture where everyone responds to call lights to first determine what the resident

needs. 68% of the time anyone can handle the situation.

Improving Staff Satisfaction: What Nursing Home Leaders Are Doing (6)

Minimize transferring an employee from one unit to another at the beginning of a shift—staff

find it really stressful to start to work on one unit and be told in 10 minutes they are working on

an other unit.

Create clear lines of communication so that employees know who to turn to when stress is a

problem.

When stressors are brought to management attention, be sure to not only listen to them but also

to do something to improve the situation.

Provide training to deal with difficult residents and families.

Provide adequate training to deal with resident behaviors.

Provide a safe way for employees to remove themselves from problem situations when stress becomes

overwhelming. Employees should be able to call for help or otherwise remove themselves before

an adverse incident occurs between staff and resident, and they should be empowered to do so.

4. Demonstrating Management’s Commitment to Consistently Fair

Performance Evaluations:

Ensure that all job descriptions are up to date and in alignment with a valid, credible

performance evaluation tool.

Educate staff regarding how they are being evaluated and what the different performance

categories and ratings address within the performance review tool.

Complete evaluations on time. An effective strategy to stay on top of getting the evaluations done

timely is to announce upcoming employee anniversaries at every management meeting with a

gentle reminder that their evaluation is due. The goal should be to complete employee appraisals

before or on their date of hire. Most employee remember their date of hire (anniversary date) and

expecting their evaluation. The importance of the evaluation is diminished when they are late.

Consider implementing quarterly mini evaluations to provide more timely, constructive, and

positive feedback to employees. No employee should have to wait for their anniversary to learn

that their work falls short.

Allow every employee the opportunity to complete a self-evaluation before the performance

review meeting. Compare their evaluation with your own and discuss it with the employee.

In order to increase the perception of “fairness” do your homework. Organize quantitative data,

qualitative thoughts and documents to support both. For licensed nurses, collect copies of audits,

make a copy of a few of their weekly summaries or change of condition notes, and notes of

praise from co-workers, physicians and family members.

Make an effort to collect more information and make sure you let the employee know of your

diligent effort. Obtain other supervisory staff members’ opinions regarding line staff. For

example, if a CNA has reported to a few charge nurses over the course of the review period, ask

each of them to provide feedback.

Choose the right time and location to ensure that the employee is in the right mind-set before

you begin the performance review.

Improving Staff Satisfaction: What Nursing Home Leaders Are Doing (7)

The reviewer’s approach going into the review should be to coach, build the employee’s selfesteem,

and move the employee closer to their potential. Therefore, conduct the review as an ex

change of information, not as a report card. The evaluation form is only a tool—a means to an

end (honest discussion). The goal should be no negative surprises for the employee receiving the

review.

Some subjects the review should cover include job proficiency, working relationships with other

employees and supervisors, relationships with the residents and their families, and how they fit

with the culture of the facility.

Performance review model—review the past (20% of discussion), analyze the present (30% of

discussion), plan the future (50% of discussion).

When beginning the performance review, be sure to obtain the employee’s comments first. Look

at their self-evaluation and highlight the areas where your ratings match. Ask probing questions

and promote self-discovery. Ask—“What do you like the most about your job?” and “What

frustrates you here?” Disagreements should be addressed through discussion and concessions on

both parties. Therefore, complete your evaluation form in pencil—and be willing to make adjustments

based on the discussion during the review.

At the end of the review—ask if the employee being reviewed felt the review was “fair.” If the

answer is “no” spending some time to work out the differences in opinion and come to a

resolution is warranted.

Wait a few days and invite the employee back to see how they feel about the review after a

period of time as gone by.

5. Demonstrating Management’s Commitment to Treating Residents With Respect.

Implement consistent assignment of the same caregivers to the same residents and abandon the

practice of rotating staff assignments. Consistent assignment allows the staff to form close

relationships with the residents.

Encourage all staff to get to know the residents beyond their current diagnosis. Allow all staff to

read the extensive information collected about each resident by the Activities and Social Service

staff.

Inform family members of your consistent assignment approach and encourage family members

to get to know their loved ones caregivers and to provide those caregivers with insights regarding

the loved ones life and lifelong habits and daily pleasures.

Educate the staff regarding why they should make the effort to form relationships with the

residents and the families and how such relationships ultimately make their job of caring for the

residents easier and more meaningful.

Embrace person-centered care and begin the process of transforming the entire organization

toward a person-centered care model.

Offer multiple opportunities for staff to learn how to deal with difficult resident behaviors. After

a resident acts out, teach staff how to analyze the event in order to come to an understanding of

how to avoid triggering that residents’ behavior in the future.

Improving Staff Satisfaction: What Nursing Home Leaders Are Doing (8)

Treat the staff with respect. The staff will treat the residents in the same manner that they are

treated by the leadership team.

Educate the staff on the leadership’s philosophy on respect for resident, families, staff and

visitors. Consider respect as a core value of the facility and promote it at every opportunity.

Find ways to reward employees that have demonstrated respect for all those they come in

contact with.

Ensure that the facility enforces strict policies and practices on the respect shown to residents

and family members.

Ensure that a system is in place for investigating reports of disrespectful treatment of residents.

6. Demonstrating Management’s Commitment to Safety:

Make sure all staff clearly understand your goal to keep everyone safe. Regularly discuss work

place safety at every general staff meeting. Express how much you care about the staff’s well

being.

Establish an active and involved Safety Committee. Include all disciplines and levels of staff as

members of the committee. At meetings report all incidents including residents, visitors and

employees. Regularly conduct a root-cause analysis of every incident including every near miss.

Let those affected participate in the root-cause analysis.

Have employees of the Safety Committee participate in safety rounds and help them to learn to

identify and report unsafe practices and unsafe working conditions. Teach them how to intervene

without causing ill will among the staff.

In the evening ensure that parking lots are well lit and considering providing escorts for employees

to their vehicles.

Show staff your facility’s safety data compared to other facilities so that they gain a clear

perspective about how your organization is performing.

Have a patient lift company do an organizational analysis on the facility and map out how to

improve lift use.

Post employee safety tips throughout the facility, in the facility newsletter, and attach safety tips

to employee paychecks.

Consistently communicate through written word your commitment to keep staff safe through

regular education and sustaining awareness. Dedicate certain weeks throughout the year where

you focus on certain aspects of safe work practices.

Have safety contests and provide rewards to the staff for working a specific number of days

without incurring a lost-time work injury.

Make sure that there is plenty of well maintained patient transfer equipment available. Regularly

check-in with the nursing staff and ask if they have enough patient lifts. Assign someone outside

of nursing to keep the patient lift batteries charged each day.

Improving Staff Satisfaction: What Nursing Home Leaders Are Doing (9)

Provide all staff with training on how to deal with difficult residents. Conduct hands-on

education regarding how to protect oneself from combative residents at least three times per

year. Ensure all newly hired staff receives the training before they are caring for residents.

Ensure that employees are protected at work from outside harassment such as spouses, bill

collectors, significant others, and so forth.

Establish a policy that prevents any personal employee information from being given out to other

persons.

7. Demonstrating Care for Staff as a Person:

Follow the suggested actions in the sections on “Management Cares About Employees” and

“Management listens to Employee” from above.

Hold regular meetings with staff to inform, educate and listen. Charge nurses should deliver a

report to the CNAs at the beginning of their shift and hold a short “huddle” meeting at the end

of the shift.

Write personal “thank you’ notes when staff members go beyond the call of duty.

Make sincere efforts to get to know each of their staff members as people.

Always monitor workflow and step in to assist staff when help is needed. Charge nurses should

provide regular, positive feedback to the CNAs.

Consistently follow up when a staff member returns from being out ill to let the staff member

know that they are concerned for their welfare and that the staff member was missed.

Write personal cards to staff on birthdays and employment anniversaries. When a CNA is

celebrating a joyful event in their life, the charge nurse should help to organize a “pot luck” get

together for the employee.

Hold occasional appreciation gatherings for the department and have cake, pizza or other treats.

Provide the opportunity for employees to have input on how their job is performed.

Provide a simple form in multiple locations that residents, visitors and, co-workers can use to

acknowledge employees for day to day acts of kindness and post.

Recognize and post achievements of units, teams, and departments so that residents, visitors and

co-workers can see them.

Take all observations, comments, suggestions from the CNAs seriously and show you act on

them—e.g., when a CNA reports that a resident has a reddened area, treat this comment

seriously and follow up with the nurse or yourself. Report back to the CNA what you found and

next steps as appropriate.

Recognize accomplishments and going “beyond the call of duty” publicly.

Deal with performance issues in private, in a respectful and caring way.

Improving Staff Satisfaction: What Nursing Home Leaders Are Doing (10)

Understand the workload of employees and manage assignments accordingly.

Understand the needs of employees in their personal lives.

The 2008-2009 Quality Improvement Committee would like to acknowledge David Farrell, SNF Management, for leading this educational project; Brad Shiverick, My InnerView; and AHCA’s Workforce Committees for their ideas and feedback. (July 2009)