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Many nursing home staff fearful of retaliation by superiors: study

By James M. Berklan

July 20, 2023


Direct care workers in nursing homes feared retaliation from managers in a significant portion of cases recently investigated, according to a new study.


The findings come on the heels of a study by the same investigator in June that discovered nursing home patients feared retaliation from facility staff.


“We talk a lot about asymmetrical power between residents and staff,” said Eilon Caspi, PhD, a gerontologist who conducted the studies. “But here we have another one between direct care staff members and their supervisors, managers and co-workers. It’s important to tell this story.


“One of the goals is to encourage (more formal) research and to undertake rigorous studies” of the dynamics between aides, nurses and their managers, he added.


Caspi told McKnight’s Long-Term Care News in a 1-on-1 interview that he believes his examination of 50 selected state survey investigations is the “most in-depth examination of this phenomenon to date.” Featured incidents took place in 26 states, at 50 different facilities. He outlined each in single-page synopses. Many 4- and 5-star facilities were among the examples, with the average facility rating being 2.81 stars.


Caspi said he found many instances where nurse aides worried about losing their jobs, favored work shifts or other desired working conditions if they were to raise subjects they thought their managers might not like. This is not the first time the subject of staff fearing retaliation in a long-term care or senior housing setting has come up in the news this year.


Caspi delivered his latest study findings in a recorded presentation, “Staff Fear of Retaliation in Nursing Homes: An Unexplored Phenomenon,” for Elder Voice Advocate of Minnesota this week.


A former nurse aide who also served as a social worker in the field, he emphasized that his findings are not an indictment of all providers.


“This is not demonizing the nursing home industry,” the 30-year sector veteran told McKnight’s. “It’s about addressing an issue that needs to be addressed. In some cases, it was the owners and (directors of nursing) who were doing the retaliation. Who’s keeping them accountable?”


CMS regulations currently state that providers must have in place a process through which employees can report suspicions of crimes or incidents without fear of retaliation. There are also F Tags (608 for reporting suspected crime and 609 for reporting suspected violations) that stipulate employees must be allowed to report suspicions of wrongdoing without fear of reprisal.


But they clearly aren’t enough, or at least aren’t being used enough, Caspi believes. An assistant research professor at the University of Connecticut, he said he undertook this study on his own initiative after USA Today and other mainstream media outlets latched onto his findings about nursing home patients’ fears of retaliation last month. That study was sponsored by the Long Term Care Community Coalition, a New York-based consumer focused nonprofit.


Fearful staff

it was not possible to determine how widespread any retaliatory practices against staff may be occurring, due to the qualitative nature of the study, he said.


“It’s tempting to think it’s a substantial concern and problem. But I’m not in a position to provide empirical evidence,” he said. “Unfortunately, I’m not aware of a way this is being centrally tracked in nursing homes. I do think it should be tracked centrally by state survey agencies and CMS if we’re serious about the risk factors and to inform prevention.


“These data apply only to a small fraction of the nursing home sector, but it’s about the human story and the lived experiences and voice of the direct care worker. Somebody has to give them a voice. It’s a meaningful enough story that the industry needs to be aware of.”


Fears of retaliation often result in a lack of reporting, or delays of it or investigations of mistreatment, Caspi said.


“My hope is that this will break the silence,” he said. “(Hopefully) it will encourage nursing homes to realize staff — all care employees’ right to work and provide care free from retaliation when they are actually deciding to express conversations about violations or lacking care or mistreatment.”


He said his “small” project probably represents “a larger, missed opportunity for early detection and investigation to address problems when they are small, to prevent harm to residents, and also respect the voice of direct-care staff members.”


Possible solutions

He said one solution would be for top management to routinely walk among staff members and proactively ask questions of all types of employees — from nurse aides to kitchen workers, housekeeping members and maintenance staff.


“Some of the best administrators will show up every morning, asking, ‘Do you need something from me? How are you doing? How can I help you?’” Caspi said. ”An extension of that is, ‘Do you feel safe noting care concerns?’ Some of the best places I’ve seen in the country tilt the organizational structure on its head.”


He explained that the risks are high and the potential penalties extremely costly for providers on the wrong side of retaliation claims.


Caspi also discussed a study of more than 500 nurses and physicians at hospitals that found that higher levels of retaliation claims were directly related to overall lower patient safety.


In non-related research, he said a study of nursing home administrators previously found that buildings run by “consensus managers” exhibited better levels of care. Consensus managers also were associated with substantially lower levels of employee turnover, he said.


“What we need is an environment built on trust. The three most important words in the field are ‘close, trusting relationships,’” Caspi said. “And that’s not just between staff and residents, but in any direction in the facility, including with staff and family members.”


Dr. Eilon Caspi's report — containing 1-page summaries of each of the 50 state survey and complaint investigation reports examined in this project — is available below:

SFSR Updated - August 30 2023
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Download PDF • 1.15MB

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