RESEARCH TO PRACTICE
Effect of Staff Turnover on Staffing Levels
in Nursing HomesKash, B., Castle, N., Naufal G. & Hawes, C. (2006). Effect of Staff Turnover on Staffing: A Closer Look at Registered Nurses, Licensed Vocational Nurses, and Certified Nursing Assstants. The Gerontologist, 46, 5, 609-619.
Research has long reported the direct relationship between low staffing levels and low quality of care in nursing homes. The long-term care industry has historically suffered from high staff turnover, and this has affected continuity of care. Consequently it has also decreased residents’ quality of care and has caused additional costs associated with staff recruitment and training. Many researchers identify that the vast majority of nursing homes report insufficient nursing staff levels.
Kash and her research team attempted to clarify the relationship between staffing levels and turnover of registered nurses (RNs), licensed vocational nurses (LVNs), and Certified Nurse Aides (CNAs) and understand the factors associated with each variable. Staffing levels and turnover rates are both critical elements for the improvement of nursing home quality.
Staffing levels were measured in hours per resident day at over 1,000 Texas nursing homes. The average number of RN hours per resident day was 0.25. For LVNs and CNAs these levels were 0.86 and 2.12, respectively. This gave a total of 3.23 hours of direct care per resident day. Staff turnover in these homes was recorded at 133% for RNs, 108% for LVNs, and at 160% for CNAs. The analysis of this data showed that staff turnover is a predictor of RN and CNA staffing levels. High turnover rates significantly reduced staffing levels for RNs and CNAs. However, LVN staffing levels were more associated with market factors than turnover.
The study also identified many factors that influence staff turnover. The research demonstrated that for-profit nursing homes experienced higher levels of RN turnover. In turn, RN turnover was found to be a significant predictor of LVN turnover. It was also identified that the ratio of contracted to employed staff was a strong predictor of LVN turnover. A higher professional staff ratio reduced LVN turnover, and in contrast, a higher contracted staff ratio mix increased LVN-turnover rates. The significant predictor for CNA turnover was the administrative management practice style. This finding validates other studies that identified a strong correlation between better management practices and reduced CNA turnover rate. The most significant predictors of staffing levels and staff turnover were organizational characteristics, like ownership status and nursing home’s resources.
An important observation was made related to wages; higher CNA wages reduced CNA turnover. However, this relationship was not found for RNs and LVNs. This finding supports a 2001 CMS report suggesting that a $2 per hour pay increase will reduce CNA turnover. Kash noticed that for-profit nursing homes offered higher wages and had lower staffing levels compared with non-profit homes. This may be because for-profit nursing homes offer higher wages to attract staff but compensate by hiring less staff.
Implications: Clarifying the relationship between staffing levels and turnover is critical for residents’ quality of care. The study identified that staffing levels are not always the outcome of staff turnover. Knowing reasons behind nursing staff turnover should help nursing home management decrease/and or eliminate the factors contributing to this problem. It is important to focus on management initiatives that are conducive to reducing CNA and RN turnover and consequently enhance residents’ quality of care and life. This may include raising wages for CNAs and reducing reliance on agency staff. When nursing staff retention rate is stable, residents usually receive high quality of care. Person-centered homes may note that missing from this research is what effect meaningful relationships have on turnover. Low staff ratios impede strong relationships because staff are forced to be task oriented rather than person-oriented.