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[This case study originally appeared in my book Shorter, pp. 184-187.]

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The Glebe is a retirement community outside Roanoke, Virginia, with two hundred residents. Like many modern retirement communities, it’s divided into sections that offer different levels of services to residents: independent living for those who are still active, assisted living for those with permanent mobility and memory issues, and skilled nursing for people who are recovering from illnesses.

In the United States, about 1.3 million people live in nursing homes, and certified nursing assistants (CNAs) provide most of their daily care. CNAs help patients in and out of bed, change dressings, assist with feeding, dressing, and bathing, and organize social activities. It’s difficult work to “provide care for people who are elderly, falling, have multiple clinical issues and comorbidities,” says Jonathan Cook, CEO of LifeSpire, the company that owns the Glebe. In most of the country, it’s also not very well paid; assistants “could be making the same amount in fast food, without dealing with bedpans and irate family,” says James Berman, a journalist who covers the industry. Many assistants have to juggle two or three jobs to make ends meet. As a result, annual turnover can exceed 100 percent in some facilities. It’s costly for nursing homes to have to keep replacing workers, and it disrupts the lives of residents. “Beyond taking care of people at the end of life, there is probably no bigger topic in long-term care than skilled staffing,” James tells me.

Despite its rural location, the Glebe has not been immune to problems of recruitment and turnover among its skilled nursing staff. In May 2018, executive director Ellen D’Ardenne started a trial in which certified nursing assistants would receive forty hours’ pay for thirty hours’ work. The 30/40 program, as they call it, is structured as an incentive program. Workers who are punctual and don’t “call off” any shifts that week receive forty hours’ pay for thirty hours’ work; if you show up late or call in sick, you lose the bonus. The six-hour day also doesn’t include time off for meals, which reduces the number of handoffs between staff and time when the facility is shorthanded. The incentive structure makes it formally stricter than shorter-hours experiments in other industries, but even places like EDGE and Woowa Brothers have cultural expectation around punctuality and presence, and of course nurses have to be on-site to do their jobs. Further, last-minute absences are costly to colleagues and facilities, who have to ask employees to work double shifts or hire expensive temporary workers.

The Glebe is not the first nursing home to try such a program. Jonathan Cook first encountered the 30/40 concept in the skilled nursing center at Marquette, a retirement home in Indianapolis. “I was just blown away at how that community was attracting and retaining—retaining being the big word—high-caliber CNAs,” he recalls. “We had a waiting list of CNAs who were waiting to come to work at Marquette. We had the choice of the cream of the crop.”

To make it work, the Glebe added nine CNAs to their staff of eighteen. This meant more money on salaries, but “based on the amount of money that we put into the ongoing recruitment efforts . . . [and] turnover costs, it was a no-brainer,” D’Ardenne told an industry magazine. The program cost $145,023 a year in wages and benefits in the first year, but it saved almost $122,762 in hiring costs, overtime, and payments to staffing services, for a total cost of about $22,261.

What did they get for their money? A year into the program, call bell response times decreased 57 percent and acquired infections dropped 65 percent. Falls and skin tears are down dramatically, indicating that nurses are more reliably available to help patients, and are doing a better job moving them. (Falls are also a leading cause of death among the elderly.) Administration of psychoactive medications is way down, because nurses can spend more time with patients and maintain continuity of care. On the staffing side, annual turnover went from 128 percent to 44 percent, and application traffic increased fourfold.

Similar experiments have been conducted in other countries. In Gothenburg, Sweden, the government-run Svartedalens nursing home conducted a two-year trial in which assistant nurses’ shifts were reduced from eight to six hours with no reduction in pay. (The trial was ended by a new, more fiscally conservative center-right government.) They had to hire fifteen more nurses, and labor costs went up by 20 percent, or €700,000 (about $735,000) during the trial; roughly half of that increase, though, was offset by savings that came with a 15 percent decline in sick days and call outs, and by taxes paid by newly employed workers who no longer drew state benefits. Residents also said that care improved when nurses had a six-hour day: nurses organized more activities and were happier and more responsive. Monica Axhede, the director of the home, told a reporter that dementia patients, who can require lots of interaction, were “clearly more peaceful” in the care of better-rested nurses. Compared to a nearby care center that stayed on an eight-hour shift schedule, nurses were healthier and less stressed. “During the trial all the staff had more energy,” Svartedalens assistant nurse Emilie Telander told the BBC in 2017. “I could see that everybody was happy.”

In health care, it’s necessary to look beyond the additional manpower expenses when assessing the total cost of programs to shorten working hours. Not far from the Svartedalens nursing home, the Sahlgrenska University Hospital moved its staff of eighty-nine orthopedic doctors and nurses to a six-hour day in 2015. It isn’t cheap—about 1 million kroner per month for an additional twelve staff—but some of those costs are offset by being able to perform more operations and having fewer patients stay in the hospital with complications. They also have dramatically shortened their waiting lists and can treat patients within weeks rather than months of a referral.