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Original Question

Daybreak Senior Care (DSC) is a 30-bed nursing home in southern California. DSC provides skilled nursing care for older adults who require assistive care after a major medical event such as a stroke or a serious fall. DSC is well-staffed for the day-to-day level of patient care with six daytime Certified Nursing Assistants (CNAs) and three on the night shift, for a total of nine front-line employees providing assistance. A well-run, well-respected facility with a five-star rating, DSC employee morale is high, and there is a positive, community feel to the organization. In March 2020, the COVID-19 pandemic began to impact California at unprecedented levels. State mandates were quickly put in place regarding best practices for safety across institutions with health care operations at the forefront of these considerations. Non-essential businesses were closed immediately. Skilled nursing facilities were considered essential businesses and all employees were considered to be essential workers. Unfortunately, this state of affairs did not constitute “business as usual.” Due to the rapid nature of the pandemic onset, almost overnight, supplies of all kinds became scarce. Skilled nursing facilities were left with limited supplies of personal protective equipment (PPE) on hand with extreme challenges in acquiring the necessary equipment for immediate and future needs of both staff and patients. COVID-19 represented a lot of unknowns for health care workers of all kinds. The symptoms of the virus were difficult to pin down and the outcomes for those who contracted the virus were varied and could be as benign as a simple cough or as extreme as respiratory failure and death. It became clear that older adults and those with underlying medical issues were at great risk of not only contracting the virus but also succumbing to it very rapidly. DSC soon became a place of fear and anxiety. Many patients were terrified they would contract the virus and die. Staff at all levels found themselves in the position of contracting the virus and then passing it along to their patients or family. It became obvious that DSC was ill equipped to support their staff at functional levels with PPE and the additional training necessary. In particular, CNAs who engaged in the highest levels of patient interaction were concerned about the lack of PPE and appropriate training. Many CNAs felt they were not appropriately compensated or protected for the level of risk and additional work they were experiencing. Monica, a CNA who had been working at DSC for over eight years, was extremely concerned. She worried about bringing the coronavirus home to her family and the possible impact this could have on each of them. Monica had two young children, a husband with asthma, and a mother-in-law who suffered with diabetes and heart disease. Monica took extra precautions in an attempt to keep them safe. These measures included changing clothes before entering the house, taking her belongings in a disposable plastic bag, and wearing gloves and a mask at all times. She did not want her family to live in fear of contracting the virus. Monica and the other CNAs quickly became disillusioned with DSC and their employment situation. In the first week of the quarantine lockdown, DSC lost two daytime and one nighttime CNA to turnover. The remaining staff were hard pressed to complete their day-to-day activities in caring for their patients. The center administrator asked the remaining CNAs to work extra hours and pick up additional shifts—without overtime pay. It became obvious to many of the staff that patient care was suffering. At about $15.00 per hour, Monica felt she was not being adequately compensated for risking her life and the health of her family. In addition, Monica was angry that the center was not providing the necessary PPE to her and the other CNAs. Supplies were extremely limited, and all of the employees found themselves reusing masks and gowns along with other supply-rationing measures. Morale at the center among the front-line employees was slipping. Nationally, the virus was taking its toll. Every day, the news illustrated the extreme outcomes being experienced by health care front-line workers across the country, especially in California. This caused additional fear and anxiety among the remaining staff. The situation prompted Monica and her fellow CNAs to ask management for a pay increase, additional hazard pay, and more PPE. Finally, they asked for additional staffing to cover shortages. They also reported the situation and demands to their union. When Monica took her concerns/demands to management, she was met with heavy resistance. In fact, she was threatened with termination if she did not fall into line. The response from management solidified the situation for the CNAs. By the end of the third week, Monica and the remaining front-line staff had not returned to work. Monica argued that low wages, difficult working conditions, and clear mishandling of the COVID-19 crisis by management made the situation untenable for her. The compensation wasn’t worth her health or that of her family. The mass exodus of front-line employees left the critical components of day-to-day care of the patients of Daybreak to a handful of higher-level employees: the registered nurses, licensed vocational nurses, and licensed practical nurses. DSC lost their critical front-line staff at a time when their presence was needed the most. Questions What protections should management place for frontline workers with family health concerns? What are some of the approaches that leadership should take to help workers deal with pandemic concerns? If you were a manager at DSC, what would be your response to Monica’s specific concerns? If you were Monica, what might you have done differently Buchbinder, S., Shanks, N., and Buchbinder, D. (2023). Cases in Healthcare Management. 2nd. ed. Jones and Bartlett Publishing. intext citations

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