BY: SUSAN McDONOUGH

Susan McDonough is vice president, strategy and system development, Covenant Health Systems, Lexington, MA.

Hospitals and health care systems today are facing the tightest labor market in the past 30 years. Although long-term care is no stranger to the challenges of recruiting and retaining qualified, committed workers, the current workforce shortage makes the task even more daunting.

Without the nurses, certified nurse aides (CNAs), and other allied health professionals to care for an aging population, the ability of Catholic long-term care facilities to continue their mission will be severely compromised.

Adding to the challenge is the fact that the demographics of today's workforce have shifted dramatically in just the past decade. According to the 2000 census, non-Hispanic whites are, for the first time, a minority population in the 100 largest U.S. cities. Today one in every four persons is Asian, African-American, or Hispanic. Almost one-tenth of the U.S. population is foreign-born. By 2010, nearly half of all the nation's new workers will be individuals traditionally classified as "minorities."

These demographic realities, combined with the health care workforce shortage, deliver a clear mandate: To compete successfully for workers in this tight labor market, we must renew our commitment to taking an inclusive approach to recruitment and retention.

In addition, the teachings of the Catholic Church call us to ensure the dignity of each of our employees. We are called to actively work to understand and celebrate differences and help each achieve his or her full potential; such help includes paying just wages. We achieve the common good when, as long-term care (LTC) and other elder care providers, we employ culturally diverse populations who mirror the communities we serve. Promoting and achieving cultural diversity in Catholic LTC facilities must be viewed as a business as well as a mission imperative.

An Evolving Concept of Diversity
In Catholic health care's mission-driven efforts to go where people need us most, many of our facilities historically have served communities with large immigrant populations. At Covenant Health Systems, many of our LTC facilities are located in urban population centers that are seeing an influx of immigrants from ever-increasing diverse cultures. Our task today is to reach out more energetically to an increasingly diverse labor pool.

This reality reinforces our understanding of how dependent we are on health care providers who come from other cultures to help us carry out our ministry. In the past, the prevailing attitude among many employers was that such people needed to "fit in" with the majority. In the 1980s and 1990s, employers became more tolerant, more accepting of the differences among people from various ethnic or racial backgrounds. Today, however, employers are increasingly aware that diversity is about inclusiveness—that actively cultivating these differences can be a strength as well as a competitive advantage.

"Organizations are realizing that diversity is not only about representation of women and racial groups but also about understanding and respecting individual differences," says David Fraser, Covenant's director of human resources. "These differences refer to ethnicity or religious beliefs, and also to gender, age, lifestyle choices, communication styles, economic backgrounds, and traditions."

For example, in one of Covenant's LTC facilities, a nursing supervisor was having a difficult time dealing with an employee who wouldn't look her in the eye. The supervisor thought the employee was being disrespectful but, in the employee's culture, it was an affront to make eye contact with a superior. When the supervisor and employee were counseled to examine the motives behind each other's actions, they realized that although both had been acting in good faith, a mutual lack of understanding had caused their behavior to be perceived in ways that were not intended.

In another situation, a staff development nurse became concerned about the English language skills of a newly hired CNA who seemed to talk very little. When the CNA was told of the nurse's concerns, the CNA began to plead eloquently for her job in very good English. It turned out that in the CNA's culture subordinates are expected to simply listen, without responding, to those in positions of authority. Had the facility had not taken the time to understand the motivation behind the CNA's behavior, it might have let go a perfectly capable employee.

Focus on Retention
Creating a positive work environment that is known to be respectful of cultural differences gives LTC facilities a powerful recruiting tool that will help them attract more people from the various cultures they are targeting. "Once a few people find a welcoming place, they refer that facility to other members of their community," says Michael Walsh, the former human resources director at Mary Immaculate Health Care Services, a Covenant member in Lawrence, MA.

Walsh describes a situation involving an immigrant from Africa. "Before he could start working for us, this man was required to have a tuberculosis test and physical," Walsh says. "His test result was positive and some additional x-ray views were needed. But this man was afraid to go to the Department of Public Health because he thought the government would deport him."

Walsh and his staff assured the man that he would not be deported and helped guide him through the public health process. "In fact, the test was a false positive," Walsh continues. "However, this was an educational experience for us. Today this man is one of our most dedicated and loyal employees. And his brother has now come to work for us, too."

"Word of mouth is definitely our strongest source of referrals for jobs," says Lori Savlon, human resources director at Maristhill Nursing Home and Rehabilitation Center in Waltham, MA, another Covenant member. "We find that our staff members from Uganda have told their friends and families about the benefits of working at Maristhill. This makes us feel particularly good because we know that we have been welcoming and respectful of their culture."

LTC facilities should examine their current recruitment and promotion policies and procedures to ensure that people are treated fairly. They should eliminate any barriers to advancement they find for particular groups.

Help Employees Achieve Their Potential
"Hiring or promoting diverse individuals isn't enough," writes Patricia Pope, chief executive officer of Pope and Associates, Inc., a Cincinnati-based consulting firm that specializes in diversity and cultural change.¹ "You have to consider the type of environment they will be moving into, and whether it provides each person the opportunity to perform to their fullest potential."

If LTC facilities are serious about their desire to be employers of choice in a diverse and fiercely competitive labor market, they need to understand what motivates each employee to be the best he or she can be. Facilities must then provide a supportive environment, including education and opportunities for people to perform at their best.

"I think there are three key issues that we must address as employers to achieve that," adds Fraser. "The first is overcoming language barriers. In the LTC setting, in particular, many of our residents have impaired hearing or cognitive impairments. A health care worker with an accent can make the situation more challenging, which makes English-language training helpful.

"Second is education and training about the cultures from which our new employees are coming," Fraser continues. "This applies to both staff and residents. With an increase in newly arriving immigrants, it's important to educate residents and families in order to dispel stereotypes. As employers and coworkers, we need to make ourselves aware of new employees' beliefs concerning aging, death and dying.

"Third, we have to help managers supervise employees from other cultures effectively," Fraser says. "Whenever there is a problem, we must make sure that the employee and supervisor involved discuss the issue at hand to make sure that each is 'on the same page.'" It is especially important for facilities with employees from several different cultures to facilitate such a discussion. For instance, in some cultures, punctuality is not important. Employees from such cultures may not realize that continually coming in late puts a strain on the rest of the team. The supervisor who sits down with a tardy employee and explains this will help that employee grow. When supervisors have been educated about developing effective corrective action plans, a win-win situation will exist.

Transportation and housing are other issues that can affect recruitment efforts. "In certain communities, rents are simply too high," says Fraser. "One of our facilities in Cambridge, MA, is looking at converting a building into temporary housing for nurses."

Fraser also points out that facilities with in-house legal counsel can provide an invaluable resource by helping immigrants navigate the visa application process. "Most long-term care facilities don't have that expertise on staff," he says. "But if you're part of a health system that does have it, or can identify community resources to which you can refer employees who need it, you'll find you have a great aid to recruitment and retention. One of our facilities in Worcester learned about a 'green card program' run by the diocese and was able to refer employees to it."

Launching Diversity Awareness
Two years ago, Covenant launched a system-wide diversity initiative with a daylong workshop entitled "Cultural Diversity and Health Care: Enriching our Heritage." We devoted an issue of our system's news magazine to the topic of culturally competent health care delivery. Our goal was to get people throughout our member, affiliate, and managed facilities to do more thinking and talking about diversity, and to signal Covenant's renewed commitment to providing a work environment that encourages and appreciates each person's contribution. We also held a follow-up education program, which included such topics as supervising a cross-cultural workforce, addressing caregiver concerns about cultural differences, understanding the impact of immigration and refugees, and providing culturally competent care to people with Alzheimer's disease. We began these programs realizing that, even if the steps we took seemed small, we had to begin somewhere. Among our initiatives are working with board nominating committees to ensure that our boards reflect the cultural composition of the communities we serve.

Meanwhile, individual Covenant facilities have undertaken a variety of diversity initiatives on their own.

Brockton, MA Maristhill Nursing Home and Rehabilitation Center and St. Joseph Manor offered a six-hour cultural diversity training program to every employee on staff. The program, conducted over a two-month period and part of a larger organizational grant program, was developed and presented by specialists from local community colleges. During Nursing Home Week, Maristhill kicked off the initiative with a special event at which participants "cruised the ports" of Uganda, Haiti, and Puerto Rico—three countries from which many Maristhill employees hail. Each "port" featured some of that country's food and cultural artifacts; some African CNAs even attended in their formal native dress.

Lawrence, MA Mary Immaculate Health Care Services has formed a partnership with nearby Northern Essex Community College's Center for Business and Industry to, first, conduct similar diversity training programs for employees and, second, hire a temporary, full-time CNA development coordinator to promote the role of the CNA within the organization. Mary Immaculate, which has a large employee population from the Dominican Republic, has also:

• Sent a cultural exchange of nursing personnel to the Dominican Republic
• Hosted a "Diversity Week" that featured food, flags, and various activities representing the different cultures on staff
• Is offering free Spanish language lessons on-site in response to employee requests

Framingham, MA Bethany Health Care Center, a Covenant affiliate, offers employees an on-site English as a Second Language (ESL) program.

Cambridge, MA Youville Hospital and Rehabilitation Center held a "Diversity Fair Week" that highlighted the 30 countries represented by its employees. The staff also raised more than $1,500 for the Catholic Charities/Youville Refugee Housing Program, which annually provides transitional housing in the Boston area for about 30 immigrants. Youville Hospital has been involved in the program since 1996. Countries represented in the housing program include the Congo, Togo, Burma, Bosnia, Iraq, Sudan, Ethiopia, Croatia, Kosovo, and Vietnam.

Covenant also is looking at ways to share across the entire system the information developed through the training grants at Maristhill.

More than a Program or Process
Creating a corporate culture of inclusiveness is not simply a program or even a "longitudinal process." Janice L. Dreachslin, PhD, author of the book Diversity Leadership, describes it as an "organizational transformation."² Seminars, workshops, and distribution of materials are just a starting point to raise awareness about diversity and to provide a foundation for making it an integral part of day-to-day operations. Creating a culture of inclusiveness requires a conscious commitment at all levels of the organization, starting at the very top.

The best way to secure "buy-in" from senior management and board members is to make the business case for diversity.

If a healthcare organization's board and senior managers are going to adopt any new initiative, they need to see how it will contribute to the organization's success. They must know that a more diverse work force will increase community support and trust, as the different groups represented come to find that your organization cares for them with sensitivity and understanding. It will improve employee morale, as employees see that they are treated fairly and given opportunities to develop. It will even enhance quality of care, because employees who feel respected and are satisfied with their jobs provide higher-quality service. ³

Being an LTC caregiver is not easy under the best of circumstances. When a caregiver also encounters misperceptions, bias, or negative attitudes in coworkers or residents, the job becomes even more difficult. Yet many such people come back day after day, because they are committed to their work as caregivers. As employers, we must nurture that commitment.

In the current health care labor shortage, creating an inclusive corporate culture that values diversity is as important as any other aspect of long-term care. By fostering a positive work environment, we will attract and retain talent that can help us advance Catholic health care's mission to provide service to the communities that need us most.

To create that positive work environment, we must understand how people perceive one another, and take the time to learn what motivates, upsets, and challenges individuals. We must recognize that everyone brings unique talents, gifts, and expectations to their jobs. And we must recognize the inherent human dignity of each individual. Doing so makes for both good mission and good business.

NOTES

1. Quoted in Julie T. Chyna, "Mirroring Your Community: A Good Reflection on You, Healthcare Executive, March-April 2001, p. 21.
2. Chyna.
3. Chyna, p. 20.

Covenant Health Systems

Covenant Health Systems, based in Lexington, MA, serves as the sponsor or manager of the following 29 health care organizations in New England. Facilities affiliated with the system are marked by an asterisk (*); facilities with which the system has a management contract are marked by a dagger (†).

Connecticut
Lourdes Health Care Center, Wilton, CT*
Matulaitis Nursing Home, Putnam, CT*

Maine
Marcotte Congregate Housing, Lewiston, ME
St. Mary's Regional Medical Center, Lewiston, ME
St. Marguerite d'Youville Pavilion, Lewiston, ME
St. Andre Health Care Facility, Biddeford, ME
St. Joseph Healthcare, Bangor, ME*

Massachusetts
Berkeley Retirement Home and Nursing Center, Lawrence, MA*
Bethany Health Care Center, Framingham, MA*
Maristhill Nursing and Rehabilitation Center, Waltham, MA
Mary Immaculate Nursing/Restorative Center, Inc., Lawrence, MA
MI Residential Community, Inc., Lawrence, MA
Mont Marie Health Care Center, Holyoke, MA*
Notre Dame Long Term Care Center, Worcester, MA*
Penacook Place, Haverhill, MA*
Sancta Maria Nursing Facility, Cambridge, MA*
St. Joseph Manor Health Care, Brockton, MA
St. Mary Health Care Center, Worcester, MA
Youville Hospital and Rehabilitation Center, Cambridge, MA
Youville House Assisted Living Residence, Cambridge, MA†
Youville Place Assisted Living Residence, Lexington, MA†

New Hampshire
Salemhaven, Salem, NH†
St. Joseph Healthcare, Nashua, NH
Holy Cross Health Center, Manchester, NH†

Vermont
Fanny Allen Hospital, Colchester, VT
Loretto Home, Rutland, VT†
Michaud Memorial Manor, Derby Line, VT†
St. Joseph Residence, Rutland, VT†
St. Joseph Home, Burlington, VT†