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Reduce Turnover and Increase Staff Retention with Employee First Culture

“Across the country, the high rate of turnover in long-term care is a serious workforce problem,” says Dr. Linda Shell, DNP, MA, BSN, DNS-CT, Chief Learning Officer, LindaShell.com. “The cost associated with this turnover—the organizational bottom line, the quality of services for residents, and the cost to consumers—is of greater magnitude. In fact, the cost of replacing a direct care worker is estimated to be about 25% of their annual wage.”

To help address these issues with turnover and staffing, Dr. Shell suggests that nurse leaders cultivate an “Employee First Culture” approach in their facilities. In this article, AAPACN will highlight important leadership skills nurse leaders can utilize to encourage staff retention, drawn from Dr. Shell’s breakout session at the 2021 AAPACN Conference, “Why Employees REALLY Leave and What You Can Do to Retain Them.”

What is Employee First Culture?

“We can ask ourselves whenever we have challenges with workforce and employee satisfaction—what have organizations outside of long-term care done?” says Dr. Shell.

Dr. Shell mentions that Southwest Airlines used to have poor customer service; however, once they developed “Employee First Culture,” all of that changed. Employee feedback had shown that staff members feeling unappreciated and disrespected in their jobs reflected in passenger interactions. Southwest made a decision to put employees first, so that the appreciation and respect they showed to their employees would trickle down to how passengers are treated, to the company’s bottom line, and to stakeholder success.

“An Employee First Culture is built on the concept that employees are the best asset of any company, and they need to be encouraged and appreciated,” says Dr. Shell. “When appreciation goes up in an organization, quality tends to go up. I really believe that for us as nurses, the more we can do to create a positive work environment and develop our leadership skills, the more opportunities we are going to have to improve the quality of care that we provide every day for those post-acute patients, as well as the residents that we serve.”

Why Some Appreciation Programs Fail

Dr. Shell notes, “Gallup did a five-year study of the workforce, and they found that 64% of people who left their jobs reported the reason was they were not feeling appreciated.”

“We often confuse saying ‘thank you’ with appreciation, and they can be quite different. ‘Thank yous’ just don’t fill the need for appreciation that employees are often seeking in their work. Now, that doesn’t mean we don’t say thank you, but it means that we need to think a little deeper about this idea of employee appreciation,” says Dr. Shell.

“Some of the common recognition programs in long-term care, such as employee of the month, a parking space, pizza parties, awards, bonus pay, company picnic, anniversary/birthday celebrations, and retirement, are often used to help people feel appreciated. But there are actually some reasons why these can fail or almost backfire for us,” says Dr. Shell.

Below are some examples of ways appreciation programs fail, according to Dr. Shell:

  • People get left out – By definition, the employee of the month program can only celebrate 12 employees.
  • Timing isn’t optimal – Day Shift may get a pizza party, but the Night Shift has to have leftovers and heat up their food.
  • Cost exceeds the value – Expensive awards programs might not produce the desired benefit for the cost incurred.
  • Difficult to be consistent/we’re busy – Sometimes it’s difficult to keep a program going; nurse leaders often get busy and aren’t able to take the time, such as when survey happens.
  • Don’t measure the success of events – After an appreciation event, many nurse leaders don’t ask the staff, “Did you feel appreciated by this recognition program that we did?”
  • The program isn’t meaningful to the staff – A pizza party may not be special to employees; some may prefer healthy food, while others may have dietary restrictions like gluten-free.

Dr. Shell stresses that these programs still have value, but that we need to be doing more to show our appreciation for staff.

New Ways to Think about Appreciation

The definition of appreciation is “a feeling of admiration, approval, or gratitude.”

As an analogy, Dr. Shell suggests thinking of appreciation as akin to “a concept we’re very familiar with—multivitamins and antibiotics. I like to think of appreciation like multivitamins. We all need to take our multivitamins every day. We need a daily dose to maintain our health. And it’s important that we get a little bit of appreciation every single day, because that keeps us and our employees healthy. But there are times, though, when we need a big dose of ‘antibiotic appreciation.’ Maybe those times when we’ve just been through a survey; maybe in the last year, when we’ve all been experiencing some really difficult times under the pandemic.” Dr. Shell suggests considering what dosage of appreciation staff might need. “When we think about our role as a nurse leader, we need to be always surveying the environment and be aware. Do your staff need just multivitamins? Are we doing good and just need to make sure we get a little bit every day? Or, do they need a big dose of ‘antibiotics,’ and do we really need to go above and beyond in offering them a big dose of appreciation to keep them inspired and keep them going through the course of their daily work?”

“When we think about Employee First Culture, we could actually do a compare and contrast with person-centered care,” adds Dr. Shell. “Person-centered care promotes choice, purpose, and meaning in daily life. It’s really a holistic view of our residents, thinking about their physical, mental, and psychosocial well-being. If we were to look at Employee First Culture, the idea of that is to promote purpose and meaning in daily life. It means that we as leaders need to understand that each employee is a whole person. They’re not just a physical person who comes to work every day, but they have a personal life that’s important to them, they may have a family that’s important to them, maybe they have community activities that they are involved in. What we do know is that they want to feel valued and respected, just as our residents want to feel valued and respected.”

Clues that Staff Need to Feel Appreciated

Dr. Shell identifies signs that nurse leaders should look out for to know when employees aren’t feeling appreciated. These include:

  • Discouragement
  • Irritability and resistance
  • Increased absenteeism and tardiness
  • Cynicism and sarcasm
  • Apathy
  • Social withdrawal
  • Negative work environment

“You might see these signs in your general workforce, and many of us are feeling that right now, just because our staff have been doing some heavy lifting for the last year. So, this could be the perfect time for you to be thinking about this Employee First Culture, this idea of putting our employees first so they will in turn put our residents first,” says Dr. Shell.

“Or, maybe you just have a few employees that you see some of these characteristics in,” notes Dr. Shell. “Often, those employees might be a new employee, an employee who is maybe struggling with some personal problems, or employees that have low self-esteem. These are often employees who need those big doses of ‘antibiotic appreciation’ versus just that daily multivitamin. So, pay attention if you have employees that you are struggling with and you’re seeing some of these signs or symptoms—it could be that appreciation could go a long way in improving the situation.”

Cultivating an Attitude of Gratitude

Dr. Shell offers some tips and strategies nurse leaders can use at an individual level to embody the culture nurse leaders are trying to promote. “If we don’t have this attitude of gratitude within ourselves, it’s going to be very difficult for you to show appreciation and for you to be grateful for those around you—for your employees, for your peers, even for your supervisor.” To help create a positive work environment, Dr. Shell suggests that nurse leaders:

  • Put your oxygen mask on first – Take care of yourself first, so that then you can take care of everyone else.
  • Write a thank you note – Writing thank you notes and expressing appreciation to someone else has been shown to increase an individual’s own sense of gratitude
  • Thank someone mentally – Even when only expressed internally, this exercise can have the same impact as writing thank you notes.
  • Count your blessings – When you focus on your blessings, you push away negative thoughts and don’t leave room for stress and anxiety.
  • Keep a gratitude journal – Write down what you are thankful for—maybe a list of 7 things you are thankful for each day, and increase the list if you can.
  • Think about 3 things you did well throughout the course of your day – Do this every day on the way home, and encourage your employees to do the same.
  • Pray or meditate – Get centered and find peace in yourself.

“One of the greatest challenges I’ve seen with directors of nursing is that we give, and we give, and we give, and suddenly we’ve given our all and left nothing for ourselves,” says Dr. Shell. “And what happens is that we start to become mediocre, and mediocre translates to burnout. And many times, it’s because we don’t take care of our own personal selves. So as a nurse leader, I challenge you to make sure you’re taking care of your own personal health—physically, mentally, spiritually, socially. All of those things are important.”

Showing gratitude to staff

In her session, Dr. Shell mentions a book by Gary Chapman & Paul White called The 5 Languages of Appreciation in the Workplace, which applies the five love language concept to the workplace. It explains that people like to be appreciated in different ways, including physical touch, tangible gifts, quality time, words of affirmation, and acts of service.

Shell suggests a variety of ways you can show gratitude that capture these different kinds of appreciation:

  • Give a verbal compliment
  • Write an email (and be specific)
  • Stop by and see how an employee is doing
  • Do something with your coworkers (not always in a work environment, but sometimes in a casual environment)
  • Do a small task for a staff member spontaneously
  • Stop by their workspace and see if they need any help getting something done
  • Buy them a coffee, drink, snack, or dessert
  • Give them a magazine or article related to an area of interest
  • Give them a high five when they have completed a task
  • Greet them warmly

Individualize appreciation for your staff

“People are looking for appreciation that is individualized and feels valuable to them. So, we need to find ways to individualize our appreciation and be able to deliver it personally when we are able to do that. And then we also need to ensure it’s valuable to the recipient so that it has impact on how they feel,” says Dr. Shell.

One way Dr. Shell suggests nurse leaders can do this by writing personalized appreciation notes, or anniversary and birthday cards. The messaging in the cards shouldn’t be general or vague, but instead recognize something very specific about the employee and what you appreciate about them. If you aren’t sure what to write, talk to other staff about the employee and get feedback about things they’ve done well.

For example, it may not be effective to write in a card: “Happy anniversary! We appreciate your contribution to the team, and wish you much more success in the years ahead.”

Instead, try: “Happy anniversary! I appreciate your contribution to the team and the difference you make to our residents. Your fellow employees tell me that you are always willing to help them when needed and the first one to tell a great joke!”

Important things to have in place for a positive work environment

“There’s some tips that are really important that if we as leaders aren’t attentive to, we will not have a positive work environment,” warns Dr. Shell. “You can show appreciation all you want, but if these things are not in place, it’s going to be really, really hard for people to feel valued and respected.”

Areas nurse leaders should keep in mind:

  • Address performance issues – Everyone should have the same expectations to do their job and know that there will be consequences if they don’t.
  • Resolve conflict/Have a conversation – Make sure you have good, strong conflict skills, and model productive conflict management. Conflicts can impact the entire team, so be willing to have those tough conversations if needed.
  • Get input from others – Don’t be afraid to ask others for input, especially on any gaps they might be seeing that you don’t. Also, rely on others for their strengths where you might have weaknesses.
  • Increase coaching and development of your staff – Make sure you’re investing in your staff.
  • Get in the habit of asking for feedback from your own supervisor – Ask your supervisor how he or she thinks you’re doing. Where are your opportunities for improvement? Ask about these so you’re always growing, learning, and developing.

How to Start an Employee First Culture

“There’s going to be 7.8 million job openings in long-term care by 2026. So, for us as nurse leaders, we have to act now. We have to find ways to reduce turnover and to increase retention. It’s really, really up to us,” emphasizes Dr. Shell.

To get started on thinking about implementing Employee First Culture and how to build on what you already have, Dr. Shell offers the following tips:

  • Assess the current work environment – How are you doing when it comes to appreciation? Is your appreciation individualized?
  • Identify which elements of Employee First Culture already exist – Consider what you are already doing well.
  • Where are the gaps? – Figure out which areas you are missing and work on those.
  • Share the idea of Employee First Culture with others – Change never happens through the leadership of one person. It takes a team of people.
  • Develop a guiding team who will spearhead implementation of this Employee First Culture – Find a team that will bring new ideas to the table and who are excited to implement this new way of approaching your culture.
  • Start small and celebrate small wins – If you don’t want to start with the whole organization, consider starting with the nursing department, or even just the nursing assistants. Break out the implementation into small goals, like trying something for two weeks and then measuring its success.
  • Be patient! – Change is hard. Big changes take an average of 7-10 years to take root in a culture.
  • Don’t quit! – Don’t give up!

After reading this article, write down one place you could start to implement this Employee First Culture. Dr. Shell says, “As you think about where you’re going to start, remember you’re going to have some real challenges, but I want you to think about what are some of the driving forces to help you make this change.”

  • Do you have an outstanding organizational mission that will be a great fit for Employee First Culture?
  • Do you have the support of leadership? Are they looking for answers to workforce challenges?
  • Do you have the support of human resources when it comes to workforce challenges and turnover?
  • Do you have staff that are asking you about workforce challenges and turnover?
  • Do you have a great nurse management team? Or do you have a great department head team?
  • Do you have an administrator that’s looking for some solutions?


“Happier employees equal happier residents, and all of that translates into higher quality of care and higher quality of life for residents,” says Dr. Shell. By implementing an Employee First Culture and evaluating that their employees feel meaning in their jobs, appreciated by the organization, and connection with their supervisor, nurse leaders can ensure their teams thrive and that their residents do too.

Note: Members who registered for the 2021 AAPACN Conference can watch Dr. Linda Shell’s session, “Why Employees REALLY Leave and What You Can Do to Retain Them” until May 22nd on the conference website.

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