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The Turnover Challenge in Skilled Nursing Facilities

This is a two-part blog series about staffing issues in skilled nursing. A subsequent blog post will present recommendations for improving SNF employee retention.

Despite the steep costs of nursing home care, substantial regulatory oversight, and the potential of penalties for unnecessary readmissions, the quality of care in our nation’s nursing homes is not adequate. Few would disagree that staffing pressures and challenges make a big contribution and need to be addressed; it is generally believed that less turnover, higher retention rates, and more staff are related to better resident outcomes.

The Magnitude of the SNF Turnover Problem

Excessive turnover of skilled nursing staff is especially problematic. “Low job satisfaction and high staff turnover prevail throughout the nursing home industry, driving costs up and quality down (Tilden et al, 2012).” Turnover rates for clinical care in nursing homes range from 55-75% with CNAs (Certified Nurse Assistants) having turnover rates which in some cases are nearly 100% (Barbera, 2014).

Factors Associated with Turnover

As mentioned above, one of the factors associated with the high cost of post-acute care is excessive turnover. Barbera (2014) summarized several factors associated with turnover in nursing homes. She indicated that facilities with higher turnover tend to be for-profit homes and offer lower levels of pay and poorer benefits. Other characteristics associated with facilities with higher turnover were staffing and work conditions. They included heavy workload, poor staffing, issues with working conditions, and work schedules not in keeping with the employee’s wishes or needs. Several other turnover-related factors related to employee characteristics. They were feelings of having little control, insufficient role clarity, feeling under-appreciated, being younger (older employees were more satisfied), and length of experience (employees with less experience were more likely leave after a short time).

Three Results of Excessive Turnover in Skilled Nursing

There are three general issues related to turnover according to a recent study by Tilden et al. (2012). These include direct costs, indirect costs, and quality of care.

  • Direct costs are associated with recruiting new employees (including advertising), orienting and training replacement employees, temp agency costs, a possible increase in injuries, and closed beds.
  • Indirect costs relate more to losing residents to other facilities and various inefficiencies that are related to high rates of turnover.
  • In relation to quality of care, Tilden et al. (2012) conducted a study on the relationship between nursing home care turnover and the quality of the residents’ experience in the dying process, in 85 nursing homes in the midwest. They found that “short-stay staff” (among RNs, LPNs, and CNAs, as well as the director of nursing and administrator) was associated with a poorer experience of dying of the resident and his or her family members (family members are often interviewed after the resident’s death to assess quality of care during the dying process). Tilden et al. found that as staff turnover increased, the quality of dying in nursing homes decreased. The researchers also ranked the 85 nursing homes from high to low on their quality scores and identified the top 5 and lowest 5. Themes of too few staff and overwhelmed staff were common among the lowest performing nursing homes but not present in the highest performing nursing homes. On the contrary, families often praised staff in the highest performing nursing homes and described how individualized care was.

A subsequent blog post will present recommendations for improving SNF employee retention.

Learn more about HealthStream’s Solutions for workforce development and compliance for Skilled Nursing Facilities.


References:

Barbera, E. F. (2014). The keys to reducing turnover in long-term care. McKnight’s. Retrieved from http://www.mcknights.com/the-world-according-to-dr-el/the-keys-to-reducing-turnover-in-long-term-care/article/333071/

Tilden, V. P., Thompson, S. A., Gajewski, B. J., & Bott, M. J. (2012). End-of-life care in nursing homes: The high cost of staff turnover. Nursing Economics, 30, 163-166.

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