Staff Turnover Rates in Nursing Homes Linked to Lower Quality of Care

High staff turnover rates in nursing homes are linked to decreased quality of care, according to a new empirical study led by Karen Shen, PhD, of the department of health policy and management at Johns Hopkins Bloomberg School of Public Health.¹

Staff turnover at nursing homes has been a concern for decades, and a recent study found that the average annual rates were 128%.

According to nationwide staffing data for Q1 2022, the average nursing home reported a nursing staff turnover rate of 53.3% and a registered nurse turnover of 51.9%.²

“Staff turnover is a challenge across the health care industry, from primary care to hospitals to specialists,” the team wrote. “These high rates of turnover can stem from a variety of sources, including burnout, poor compensation, and poor training and support.”¹

To improve the quality of care in nursing homes, health professionals used to focus on increasing staff levels, but now they are focusing on reducing staff turnover. The turnover concern at nursing homes has now become a “critical need of investment,” following the COVID-19 pandemic, investigators noted. In February 2022, the Biden administration proposed policy reforms to increase staffing, to uphold a federal minimum staffing requirement.

“Our results suggest that additional policy reforms that increase staff and administrator retention may provide an additional pathway to improve quality,” the investigators wrote.

Shen and colleagues conducted a cross-sectional study of data from the Centers for Medicare & Medicaid Services (CMMS) on health inspection citations examining quality measures at US nursing homes. They also combined the data with turnover measures discovered through daily staffing payroll data for Q2 2017 to Q4 2019. Investigators examined 1.06 billion shifts for 7.48 million employment relationships at 15,869 facilities.

The investigators used a 2-way fixed-effects sign to calculate the association between staff turnover and quality of care. Data analysis took place from September 2022 – August 2023. The sample they used included 1.45 million facility-weeks between April 2017 - December 2019, comprising of 13,826 facilities. They collected data on administrators and direct care nursing staff, including registered nurses, licensed practical nurses, and certified nursing assistants.

The investigators defined faculty turnover as anyone who had been hired within the past 90 days. On an average week, 15% of nursing staff and 11.6% of administrators were new hires due to the high turnover rates.

The team used a CMS Nursing Home Compare star rating system to determine the quality-of-care outcomes—the system included outcomes from routine health inspections and quality measures (QMs).

Ten QMs were measured, which included the percentage of long-stay residents who needed more help with activities of daily living, the percentage of short-stay residents who improved in function, and the percentage of short-stay residents who were re-hospitalized after staying at a nursing home.

For direct care nursing staff, 15% of the nursing hours were provided by employees hired within the past 90 days. Meanwhile, for administrators, 11.6% of the hours were provided by new hires.

On average, 16% of certified nursing assistants, 13.1% of licensed practiced nurses, and 13.9% of registered nurses quit within their first 90 days of the job.

In the 22,956 facility health inspections for the same of facilities, 94% of the citations were for infraction with little severity (and thus no actual harm). Yet inspections included 2770 citations of actual harm and 923 citations of immediate danger. About half (51%) of the citations were deemed isolated, and 49% were of pattern or widespread scope. Quality-of-care was the largest category of citations.

Ultimately, increases in nursing staff turnover were associated with decreased performance on health inspections. A turnover increase of 10 percentage points was associated with 0.241 citations in the health inspection (95% CI, 0.084 - 0.399).

The team found a negative association between turnover and quality of care, estimating that a 10-percentage point increase in staff turnover was associated with lower scores in the composite assessment-based QM by 0.035 (95% CI, 0.023 - 0.047).

Also, a 10-percentage point increase in administrator turnover is associated with a QM score reduction of 0.019 (95% CI, 0.014 - 0.024).

Though, when the investigators controlled for the turnover measures, they found the relationship between nursing turnovers and quality of care were not statistically significant. For QMs, only 3 were statistically significant.

There was a large association between turnover and long-stay residents experiencing a worsened experience of daily living (95% CI, 0.024 - 0.050), as well as 0.038 for a mobility score (95% CI, 0.025 - 0.052).

The team concluded from their findings that measures to financially incentivize nursing home care giver retention may help the prevalent issue of turnover in most facilities.

“Some examples [of policy reforms] that regulators and policymakers could consider include Medicaid or Medicare wage pass-through requirements (which require that a specified portion of reimbursement rate increases go toward increased staff wages), supplemental payments for the use of longer-tenured staff, funding for continued education and training for staff, and increasing the prominence of staff tenure and experience in Nursing Home Compare,” the investigators concluded.

References

1. ^{Shen, K, McGarry, B, and Gandhi A. Health Care Staff Turnover and Quality of Care at Nursing Homes. Jama Internal Medicine. 2023. doi:10.1001/jamainternmed.2023.5225}
2. ^{Long Term Care Community Coalition. LTCCC Alert: Nursing Home Staff Turnover Above 50%. https://nursinghome411.org/alert-staffing-q1-2022/#:~:text=Staffing%20Facts%20for%20Q1%202022,staff%20turnover%20rate%20of%2051.9%25. Accessed October 9, 2023.}