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Improve Staffing and Quality Care Through Individualized Culture Change of the Nursing Department

Staff turnover is a nationwide problem for nursing homes and it may be worse than previous reports have suggested, according to a study of newly available Payroll-Based Journal data published in the National Library of Medicine. The study also noted a possible negative relationship between a facility’s overall Five-Star rating and turnover rate, suggesting staffing issues are also potential quality issues. Staffing instability has been linked with lower nursing home quality, according to another recent study posted on JAMA Network.

Several factors impact staff turnover. One area where the director of nursing services (DNS) can make a difference is to create a positive culture in the nursing department that attracts and retains employees. The DNS should assess the nursing department’s culture regularly to see if any action is called for and if any areas need improvement. When the DNS ensures a positive and healthy work culture, he or she can help improve staff retention and reduce turnover.

This article discusses how culture change isn’t a one-size-fits-all approach, how to assess and address a culture problem in the nursing department with the help of the quality assurance and performance improvement (QAPI) committee, different areas of assessment, and explains why effective culture change is always a team effort.  

Culture change isn’t one-size-fits-all

Culture in long-term care varies from building to building, says Jessica Shepherd, BSW, LNHA, nursing home administrator for Oneida Nursing and Rehab Center in Oneida, TN. “Two buildings can sit side-by-side and have a very different culture and environment. However, that’s okay. What works for one building might not work for another, but the result should always be giving residents the best care possible.”

As culture varies, the kind of change needed within nursing departments can be just as diverse. For example, nurses in one department may struggle with gossip; in another facility, the staff may feel alienated by a micromanaging leader.

These cultural issues can impact the work environment for employees, such as working short due to turnover or feeling unmotivated or resentful. And importantly, the quality of care provided to the residents may also suffer as the negative impacts of these issues trickle down. To address these various challenges and work toward a positive and healthy work culture where employees can thrive and want to come to work at the facility and residents receive top quality care, the DNS should first explore what’s not working with the help of the QAPI committee.

How to address a culture problem through QAPI

When the DNS identifies a staffing issue in the nursing department, he or she needs to investigate the problem and conduct a root-cause analysis, says Jennifer Goodpaster, BS, RN, DNS-CT, QCP, RAC-CT, CPHQ, curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN). “The QAPI committee can help with that. They should put a team together and look at what’s going on. The team should consist of who might be involved in the issue, such as roles involved in the hiring process or in the human resources (HR) department.”

When starting an improvement initiative, the DNS can begin by looking at the data available, the turnover rate and retention rate, advises Goodpaster. “The turnover rate will reveal how many employees left and the retention rate will show how many employees stayed during a chosen time frame. These two data points are important to see the extent of the staffing problem from a high level.”

However, it’s also key to look at which roles are leaving and how long they are staying, adds Goodpaster. “Determining which roles may be affected can help pinpoint a workload or management issue. For example, if most of the employees leaving are certified nursing assistants (CNAs), the committee can delve into what makes that role specifically challenging.”

In contrast, looking at how long employees are staying could offer insight into what kind of staffing issue needs to be addressed, says Goodpaster. “For example, if employees are leaving after 90 days from their hire date, then the facility likely has a retention issue. If employees are leaving before 90 days, then the facility likely has an onboarding issue.”

Once the QAPI committee identifies the kind of problem, they can dig deeper into the causes, says Goodpaster. “They can then ask, ‘Why are we failing to retain our employees? Why are they going somewhere else? Are our benefits, such as time off, not as attractive anymore in relation to other facilities in the area? Or what may be the issue with the onboarding process that we could address and what improvements can be made? Do our CNAs feel prepared, supported, and confident in their new role, or are we failing to provide the education and mentoring that can help them succeed?’”

Note: For a deeper dive into all aspects of QAPI from theory to application-based strategies, consider enrolling in AAPACN’s QAPI Certified Professional (QCP) education and certification program. Also, leaders can review AAPACN’s Onboarding Essentials: Welcoming Staff to Promote Retention Tool to help facilitate a successful onboarding experience for new employees.

Assess culture from multiple vantage points

Addressing major culture issues through QAPI can have a significant impact on the stability of the nursing department’s staff and quality of care. Next are some suggested vantage points to assess the current culture and ensure the DNS is leading the way to make the nursing department the best place to work.

The nursing staff’s values

A critical component for a positive and healthy culture in the nursing department is knowing the values of your staff, says Goodpaster. “What drives them? After you know what your staff values, you can pull out the similarities and understand what motivates your staff to stay and show up and come to work every day.”

The DNS can then evaluate whether the nursing department is doing everything possible to motivate the staff based on their values, says Goodpaster. “For example, do employees feel recognized enough for their achievements? How are we rewarding staff and recognizing a job well done? Are we doing that, or are we only educating and disciplining—only giving staff our attention when things go wrong?”

Leadership style of the DNS

Culture change also begins with self-assessment, suggests Goodpaster. “As a leader, you have to ask yourself if you are providing an environment in which your employees can thrive.”

Leadership shouldn’t micromanage staff, cautions Goodpaster. “It’s important to give employees independence and autonomy so that they can gain confidence, too. You need to show that you trust your staff to do their jobs. Sometimes, that’s a hard task for DNSs who want to make sure everything is going right all the time.”

“However, when you have the right people with the right skills and values, who align with the organization’s values, you shouldn’t have to worry about their performance and can let them take on the responsibility that they need to be a team player,” says Goodpaster. “It’s okay to follow up to make sure that everything is being handled properly and to educate when it isn’t, but you have to have trust in your team to do their jobs.”

A transparent and safe communication space

“It’s important to be transparent and communicate with your staff,” says Goodpaster. “Let the team know what is going on in the organization. Is there anything happening that could impact resident care? Providing this information helps to build trust and rapport with the team and helps them feel included and knowledgeable about facility changes.”

“The team should also be comfortable coming to talk to you,” adds Goodpaster. “When the DNS has an open-door policy, where staff can come in and express their concerns and get feedback, discuss what’s working and not working for the team, this will not only provide helpful insight for the DNS into any issues, but staff will be more motivated working for a leader that they can confide in rather than feel they have to keep issues to themselves.”

The DNS and administrator set the example

“The DNS and the administrator need to have a strong working relationship to help lead their team forward,” notes Goodpaster. “They don’t always have to agree, but they need to work through issues as a team.”

“The rest of the team also looks to both the DNS and administrator for the behaviors they need to emulate and follow,” adds Goodpaster. “Therefore, leadership needs to lead by example and model expectations such as how to work as a team, how to get along and support each other, and how to respect one another.”

“It all goes back to values,” says Goodpaster. “If you lead by example and show others what the values of the organization are through your actions, then that’s going to show the standards to your staff.”

“You put into the universe what you want to receive,” agrees Shepherd. “If I want positive employees who are honoring the culture of our environment and our patients, then I must lead by example. Teamwork, respect, and understanding are important values to me as a leader, and I try to show them every day.”

Note: AAPACN recently developed the Nursing Department Culture Assessment and Improvement Worksheet to help the DNS and administrator review multiple areas of the nursing department’s culture that they have observed and adjust where needed.

Culture change is a team effort

To improve the facility’s culture, the DNS should check in with staff while rounding and promote employee engagement, says Goodpaster. “Ask staff, ‘Is there anything that you need? Is there anything that’s not working? Do you have any concerns? What’s working great?’ By checking in with the team, providing praise for things they are doing well, welcoming their feedback, following up if something isn’t working, and letting staff assist with decisions on improvement efforts, the DNS creates a relationship where staff and leadership are working together for improvement. When staff are asked for their input and know their feedback is valued and addressed, they will feel like they have some control over any issues that arise.”


When everyone is working together for the best team environment, when leaders are assessing their department’s culture and their own impact on that culture, and culture problems are addressed readily, residents can receive the highest quality of life and care.

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