Turnover in Skilled Nursing Facilities – Impact and Solutions

April 1, 2021
April 1, 2021

This is the second in a two-part blog series about staffing issues in skilled nursing.

Not much attention has been paid to the effects of poor retention of skilled nursing staff. However, the literature supports the importance of retaining them. One study found that RNs that had been employed five years or longer at the same facility were associated with less dependence on restraints, less pain levels, lower levels of pressure ulcers, and fewer indwelling catheters [Castle and Engberg (2008) in Thomas et. al (2012)].

A study was conducted by Thomas et al. (2012) with 681 nursing homes in Florida between 2002-09. They used nursing home facility-level data and staffing reports and controlled for patient demographics and ownership characteristics of the facilities. They found that the licensed nurse retention rate was significantly related to the 30-day readmission rate. Furthermore, a 10% increase in licensed nurse retention was associated with a 0.2% lower readmission rate. This translated into two less hospitalizations per year per nursing home. Their research emphasized the importance of retention and the critical value of “stayers.”

Factors Associated with Staff Retention

Barbera (2014) identified a number of factors associated with retention. They were:

  • Involvement in interdisciplinary care plan meetings
  • Length of experience (those with more experience were more likely to remain on the job)
  • Older workers (who tended to have more stable family situations)
  • Performance of exemplary care demonstrated through performance of restorative care (for aides)
  • Opportunities for professional growth
  • Supervisory training
  • Sufficient orientation (experienced workers felt new employees weren’t properly oriented and prepared for the volume of work)
  • Motivating positive feelings between aides and residents
  • Perception of being valued by nurses and supervisors
  • Being considered an important part of the care team
  • Working as a team
  • Positive relationships with coworkers
  • Permanent assignments 

Advisor Recommendations for Reducing Turnover

Barbera (2014) summarized several suggestions to reduce turnover. These have been categorized in three areas. The first intervention category relates to the professional development of staff and includes things like providing opportunities for professional growth, training supervisors in coaching techniques, including employees in decision-making, recognizing employees for their accomplishments, and assisting employees with stress management.

The second category includes ideas to improve staff autonomy like involving more staff in care planning and creating options for self-scheduling. The third category applies to administrators. It includes things like clear communication of expectations, confronting under performance, team building, staff support, calling staff by names, increasing the number of staff per resident, and recruiting more appropriate employees (by assessing interests and motivation).

Lastly, Collier and Harrington (2008) recommended three staffing guidelines which should be tested and evaluated as to their effect on the quality of resident care (p. 167).

  • Total minimum direct care staffing levels of 4.1 hours of care per resident day, which should be subject to change to account for differences in resident case-mix or comorbidity measures as required by the NHRA.
  • Direct care RN staffing levels of 0.75 hours of care per resident day, not including administrative RNs, which should also reflect differences or changes in resident case-mix characteristics.
  • 24-hour RN staffing

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


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/

Castle, N. G., & Engberg, J. (2008). Further examination of the influence of caregiver staffing levels on nursing home quality. The Gerontologist, 48, 464-476.

Collier, E., & Harrington, C. (2008). Staffing characteristics, turnover rates, and quality of resident care in nursing facilities. Research in Gerontological Nursing, 1, pp. 157-170.

Thomas, K. S., Mor, V., Tyler, D. A., & Hyer, K. (2012). The relationship among licensed nurse turnover, retention, and rehospitalization of nursing home residents. 53, 211-221.