Hiring qualified staff a serious challenge for homes
Turnover rate over 100 percent, according to some estimates

Sidebar to Part 1

In September, nursing assistant Tim Simpson and licensed practical nurse Audrea Storer faxed a list of complaints about working conditions at Hospitality Home West in Xenia to the home's Massachusetts headquarters. At the top of the list, signed by 20 other employees, was inadequate staffing.

Simpson said short-staffing means leaving the special care unit for Alzheimer's patients open at night so staff can see and hear into the unit rather than stationing an aide there. "When there's only four aides in the whole building (of 100 residents), you can't have one of them tied up on that locked unit," he said.

As a result, he said, one patient left the building late one night in August and was later found dressed only in her nightgown at Dave's Market several blocks away.

LISA POWELL/DAYTON DAILY NEWS KEITH MARSHALL, a nurse's aide student, learns how to read a thermometer under the guidance of Vicki Hays, an instructor at Miami Jacobs Nurse Aide Training Center in Dayton. Debra Meador, who heads the program, says many qualified nursing assistants choose other jobs. 'I think there's a shortage of nursing assistants who are working. I know, because I train close to 600 a year. The problem is, they just don't work (in the field.)'

A week after Simpson and Storer's memo, Hospitality Home called a mandatory staff meeting, where administrators said they would look into the open door problem.

Simpson and Storer weren't around to see if any changes were made. Within a month, both were fired.

"We're being punished for speaking up for residents, because we care about them," Simpson said. "Somebody has to speak out. These are human beings that we're talking about in this nursing home."

Richard Giles, administrator of Hospitality Home, said the firing of Simpson and Storer had nothing to do with their complaint about staffing, but said he couldn't elaborate on a personnel matter.

"There is no staffing issue in this particular facility," he said.

If so, it may be in the minority. Recruiting enough qualified caregivers is a serious problem according to nearly half of the Ohio nursing homes (43 percent) and home health agencies (47 percent) recently surveyed by the Scripps Gerontology Center at Miami University.

Nursing assistants and home health aides "are the frontline of the elder care system," providing 80 percent of the hands-on care to patients, said Jan Straker, the Miami University researcher who headed the survey.

Aides, who can obtain state certification with just two weeks of training, face incredible demands. They must make sure residents are clean, fed, getting enough fluids and are properly clothed, that they are taken to the toilet when needed, that they are turned in bed to prevent bedsores and that they have a chance to walk, talk and engage in social activities. And often they must deal with difficult or abusive residents and unhappy families.

A report this year by the Ohio Academy of Nursing Homes, a trade association of more than 200 for-profit homes in the state, calls staff recruitment "Ohio's health care crisis . . . a declining number of (caregivers) at a time when (health care) employers are experiencing unprecedented, unchecked growth."

Licensed beds in Ohio's assisted living facilities more than doubled in the five years between 1994 and 1998, while home health agencies showed similar increases in clients needing services.

Those programs are competing for a dwindling pool of caregivers, many of whom have been lured to higher-paying, less stressful jobs in a strong economy.

Increasingly, Ohio's nursing homes are relying on temporary agencies to meet their needs. From 1995 to 1997, the purchase of temporary aide services grew 26 percent, from $22 million per year to nearly $28 million, industry sources say.

By some national estimates, Straker noted, the annual turnover rate among nursing home aides exceeds 100 percent per home and approaches 75 percent for home health agencies.

And more of them will be needed as more Americans age. In Ohio alone, the demand for personal care aides is expected to increase 85 percent between 1994 and 2005, according to the Ohio Bureau of Employment Services.

Debra Meador, who heads the Nurse Aide Training Program for Miami Jacobs College in Dayton, insists there's no shortage of qualified nursing assistants. "I think there's a shortage of nursing assistants who are working," she said. "I know, because I train close to 600 a year. The problem is, they just don't work (in the field.)"

Meador blames low wages, benefits and working conditions. "It's an eight-hour-on-your-feet job where you do total patient care," she said. "It's like taking care of infants, but they're adult-sized . . . A lot of my aides found they could go to work at McDonald's and make the same money and they don't have to work nearly as hard."

Lack of benefits can be a major deterrent as well, especially for single mothers. "I hear this constantly from my former students," Meador said. "If they pay for the (health) insurance to cover their families, they have no money to live on. Most places require a 50-50 split on premiums and co pays."

Peter Van Runkle, chief legal advisor to the Ohio Health Care Association, the largest trade association of nursing homes in Ohio, said the industry has raised wages and benefits for aides -- an average 6.3 percent hike between 1997 and 1998 alone, when inflation was running at less than half of that (2.6 percent). The average hourly pay is well above minimum wage, he said, "around $8 an hour."

Van Runkle said the staffing shortage won't be solved by throwing more money at it. "Higher pay and benefits is helpful in some cases, but what we're really looking at is a shortage of available bodies. We're competing in the same market as retail sales and fast food. Everybody is trying to find people."

The Service Employees International Union (SEIU), which represents thousands of nursing home aides and nurses across the country, and the National Citizens' Coalition for Nursing Home Reform are lobbying for tougher staffing guidelines for nursing homes. Twenty states are now considering an increase in nursing home staffing levels, but so far just one state -- Wisconsin -- has succeeded in making them law.

'It's an eight-hour-on-your-feet job where you do total patient care. It's like taking care of infants, but they're adult-sized . . . A lot of my aides found they could go to work at McDonald's and make the same money and they don't have to work nearly as hard.' DEBRA MEADOR Who heads the Nurse Aide Training Program for Miami-Jacobs College in Dayton

A bill that may get a hearing in the Ohio legislature in January would require one nurse's aide for every five nursing home patients during the day and one aide for every 15 patients at night.

The current state requirement, adopted in 1974, is one caregiver of any kind to 15 patients.

"You can have dietary people, you can have maintenance, you can have housekeeping. As long as they're in the building, they're (now) included in the ratio," said Peggy Kearsey, political director of District 1199/SEIU in Columbus. "We want to close that loophole and give patients they care they deserve."

But Van Runkle said mandating more aides ignores the cost to taxpayers and the current realities of a tight labor market.

The current average staffing ratio in Ohio's nursing homes, he said, is one nursing assistant to 11 patients and one nurse to 17 patients -- well within the state requirement.

"Staffing ratios are not relevant," Van Runkle said. "It's a far too simplistic way of approaching the provision of (quality) care . . . The proper staffing mix and ratio has to do with so many variables," including the needs of the patients and the capability of the staff.

Reducing the ratios would also likely come out of taxpayers' pockets. Medicaid, administered by the state, accounts for 70 percent of the nursing home industry's revenue, and the state spent $1.7 billion in Medicaid funds on nursing home care in fiscal year 1997.

Some homes are trying to improve retention and professionalism by offering aides additional training beyond state requirements and a boost in pay. Carriage by the Lake in Bellbrook, a home operated by Integrated Health Services Inc. in Maryland, recently launched a program that creates "senior nursing assistant" positions for aides who take an additional 30 to 60 hours of training designed at Cornell University. Once they finish the training, they receive an extra dollar an hour in pay and are qualified to act as mentors to less experienced aides.

Straker, the Miami University researcher who headed the Scripps survey on staffing problems, said researchers found no conclusive link between a home's turnover rate and its salaries and benefit structure. But one thing was clear, she said, homes with lower turnover rates did a better job of showing their appreciation for employees and getting them involved in decision-making.

That didn't surprise Meador.

"A lot of nurse's aides come from backgrounds where they didn't get a lot of attention, didn't get a lot of strokes, and yet they like to give them (to patients)," she said. "Administrators need to remember what it's like to be at the bottom of the line."