Facility-Level Factors Associated With CNA Turnover and Retention: Lessons for the Long-Term Services Industry

The Impact of Nursing Home Culture Change: An Integrative Review

OBJECTIVES

The Nursing Home Culture Change (NHCC) movement promotes a person- and relationship-centered approach and a small-scale, homelike model for NHs. The present study aimed to integrate the most recent empirical findings regarding the impact of NHCC on resident, staff, family, and organizational outcomes.

DESIGN

Integrative review.

SETTING AND PARTICIPANTS

Not applicable.

METHODS

OVID MEDLINE, PsycINFO, Embase, and CINAHL databases were searched for quantitative or mixed studies published in English between 2018 and 2022 and examining the effect of NHCC on resident, staff, family, and/or organizational outcomes. A narrative and tabular synthesis of the results is provided.

RESULTS

A total of 1687 references were identified. Following duplicate removal, title and abstract screening, and full-text screening, 75 studies were retained for synthesis and suggest a positive impact of NHCC on resident (eg, quality of life and neuropsychiatric function), staff (eg, job satisfaction and stress), family (eg, satisfaction and depressive symptoms), and organizational (eg, NH attractiveness and occupancy rate) outcomes.

CONCLUSIONS AND IMPLICATIONS

NHCC shows promising results in all studied outcome categories. Future research should further investigate obstacles to NHCC implementation, conduct cost-benefit analyses supported by appropriate statistical tests, and define ways to improve NH staff education as well as NH policies and regulations to better support NHCC initiatives.

Improving the Recruitment and Retention of Unlicensed Assistive Personnel: A Quality Improvement Initiative

With increasing demands for unlicensed assistive personnel, strategies for optimizing recruitment and retention are paramount. The purpose of this quality improvement project was to increase the recruitment and retention of unlicensed assistive personnel in a nonprofit healthcare organization. Initiatives included expanding academic affiliations enhancing pipeline, developing a tailored onboarding program, and introducing a clinical ladder. Results indicate increases in numbers of academic affiliations and hiring, with unlicensed assistive personnel turnover rates below national averages.

Nursing assistant turnover in nursing homes: A scoping review of the literature

BACKGROUND

Nurse aide turnover in long-term care is projected to increase in the coming years. Guided by a social ecological framework, this scoping review systematically searched for peer-reviewed journal articles on nursing assistant or nurse aide turnover in nursing homes.

METHODS

Using the PICO and PRISMA guidelines, 8 university-based library databases via EBSCOhost were searched to source peer-reviewed journal articles published between 2002 and 2022 on nurse aide turnover in nursing homes.

RESULTS

The initial article search revealed 997 articles. After a three-stage article screening and removal process, a final sample of 43 articles (N = 43) remained. Guided by levels of influence, nurse aide turnover is found to be influenced by intrapersonal, interpersonal, institutional, community, and public policy level factors.

CONCLUSION

Findings highlight the need for further research with nursing facility administrators and nurse aides to evaluate the complex interactions within long-term care nursing homes.

Job Characteristics Associated With Intent to Quit Among Nursing Home Employees and Managers

BACKGROUND AND OBJECTIVES

High turnover and recruitment challenges of nursing home employees and managers are an ongoing concern. This study's objective was to examine intent to quit among all staff and assess the roles of job characteristics and job satisfaction. Employees and managers within one nursing home chain working in direct patient care or nursing were compared.

RESEARCH DESIGN AND METHODS

Data came from the Work, Family, Health Network 18-month follow-up survey in 2012 (total = 1,000, managers = 101, employees = 899). A cumulative logit model controlling for demographics was estimated for intent to quit. Herzberg's Two-Factor Theory of Work Motivation guided the study.

RESULTS

Employees scored significantly lower on family-supportive supervisor behaviors (FSSBs), schedule control, and decision authority than managers. Employees and managers did not differ on job satisfaction, intent to quit, or job demands. Satisfied workers had an 83% decrease in the odds of reporting an intent to quit compared to workers who were neutral or disagreed (odds ratio [OR] = 0.17, p < .0001). Decision authority (OR = 3.49) and schedule control (OR = 5.18) were independently related to greater odds of reporting an intent to quit. In contrast, FSSBs (OR = 0.69), safety compliance (OR = 0.71), and the combination of high decision authority with high schedule control (OR = 0.72) were related to lower odds of reporting an intent to quit.

DISCUSSION AND IMPLICATIONS

Among nursing home staff, lower intent to quit may be achieved through improving job satisfaction, the quality of supervision, safety culture, and job enrichment through more schedule control and decision-making power.

Does Higher Worker Retention Buffer Against Consumer Complaints? Evidence From Ohio Nursing Homes

BACKGROUND AND OBJECTIVES

This study examined the relationship between nursing home (NH) quality using consumer complaints and certified nursing assistant (CNA) annual retention rates among Ohio freestanding NHs (n = 691).

RESEARCH DESIGN AND METHODS

Core variables came from the 2017 Ohio Biennial Survey of Long-term Care Facilities and Centers for Medicare and Medicaid Services Automated Survey Processing Environment Complaints/Incidents Tracking System. To compare NHs, 4 quartiles of CNA retention rates were created: low (0%-48%), medium (49%-60%), high (61%-72%), and very high retention (73%-100%). Negative binomial regressions were estimated on total, substantiated, and unsubstantiated allegations and complaints. All regressions controlled for facility and county-level factors and clustered facilities by county.

RESULTS

NHs in the top 50% (high and very high) of retention received 1.92 fewer allegations than those in the bottom 50%, representing a 19% difference; this trend was significant and negative across all outcomes. Using quartiles revealed a nonlinear pattern: high-retention NHs received the fewest number of allegations and complaints. The differences between high and low retention on allegations, substantiated, and unsubstantied allegations were 33% (3.73 fewer), 34% (0.51 fewer), and 32% (3.12 fewer), respectively. Unexpectedly, very high-retention NHs received more unsubstantiated allegations than high-retention NHs.

DISCUSSION AND IMPLICATIONS

While higher-retention should result in fewer complaints, our results indicate that some turnover may be desirable because the very high-retention NHs performed slightly worse than those with high retention. Among the remaining facilities, fewer complaints may be achieved by improving CNA retention through higher wages, career advancement, and better training.

Recruitment, retention and employment growth in the long-term care sector in England

This paper studies the relationship between turnover, hiring and employment growth in the long-term care (LTC) sector in England and sheds light on how challenges in both recruitment and retention affect the sector's ability to meet growing demand for care services. Using the Adult Social Care Workforce Data Set (ASC-WDS), a large longitudinal dataset of LTC establishments in England, and fixed effects estimation methods we: (a) quantify the relationship between the in/outflow of care workers and the expansion/contraction of employment within establishments, (b) establish the role of staff retention policy for workforce expansion, and (c) identify the role of recruitment frictions and its impact on hiring and employment contraction. Our analysis indicates that care worker turnover and employment growth are negatively related. A one percentage point increase in employment contraction is associated with a 0.71 percentage point rise in turnover, while a one percentage point increase in employment expansion is associated with a 0.23 percentage point fall in turnover. In contrast, we find that hiring rates and employment growth are positively related. A one percentage point increase in employment expansion is associated with a 0.76 percentage point rise in hiring, while a one percentage point increase in employment contraction is associated with a 0.26 percentage point decrease in hiring. We argue that the negative turnover-employment growth relationship within expanding establishments provides evidence that better staff retention is associated with higher employment growth. Using information on establishments' annual change in vacancies, and controlling for changes in new labor demand, we also find rising year-on-year vacancies amongst establishments with declining employment. This provides evidence that recruitment frictions drive the declining rate of replacement hiring amongst contracting establishments. Across sectors, we find that the employment growth-turnover and the employment decline-hiring relationships are relatively stronger in the private and voluntary sectors compared to the public sector, suggesting that the impact of staff retention and recruitment frictions on employment is more acute in these sectors.

Association between wages and nursing staff turnover in Iowa nursing homes

Background and Objectives

Nursing staff turnover is a substantial concern for nursing homes that care for millions of older individuals, especially during the COVID-19 pandemic. Low pay is considered as one of the key reasons for high turnover. However, we do not know whether increasing wages can lead to lower turnover. In this study, we fill this gap in our understanding by analyzing the relationship between wages and nursing staff turnover.

Research Design and Methods

We obtained data on hourly wages (Medicare Cost Reports), turnover (Iowa Department of Human Services), and nursing home and resident characteristics (Nursing Home Compare and LTCFocus) from 2013 to 2017. We summarized the characteristics of nursing homes as well as turnover trends over time. Next, we used pooled OLS and facility fixed effects regressions to examine the relationship between wages and turnover adjusting for nursing home and resident characteristics.

Results

Among the 396 nursing homes in Iowa, average hourly wage was $27.0 for registered nurse (RNs), $21.6 for licensed practical nurses (LPNs), and $14.1 for certified nurse aides (CNAs) during 2013 to 2017. Average turnover rates were increasing over time for all staff types and in 2017, turnover rates were 46.0% for RNs, 44.4% for LPNs, and 64.7% for CNAs. In both pooled OLS and facility fixed effects regressions, higher wages were associated with lower turnover of CNAs but not LPNs or RNs. The magnitude of the effect of wages on turnover for CNAs was lower in facility fixed effects regressions.

Discussion and Implications

We found significant relationship between hourly wages and turnover for CNAs but not for LPNs or RNs. Focusing on higher wages alone may not lead to lower turnover of all types of nursing staff in nursing homes. We should also focus on non-wage factors related to turnover.

Staff Stability Through Service: Promoting a Person-Centered Culture for Work and Care in Long-Term Services and Supports Environments

Nursing homes have struggled for years to secure and retain staff. Turnover of all staff, from administrators to direct care providers, continues to plague the industry. Although improvements in compensation, benefits, and opportunities for promotion may enhance retention, organizational culture may also play a major role. The current article discusses the SERVICE Model of Leadership^©, which can improve the culture and promote staff retention through the establishment of systems and programs that meet the reported needs and desires of all staffing levels in nursing homes and other organizations providing long-term services and supports. [Journal of Gerontological Nursing, 47(11), 6-10.].

Organizational Factors Associated With Retention of Direct Care Workers: A Comparison of Nursing Homes and Assisted Living Facilities

BACKGROUND AND OBJECTIVES

Low retention of direct care workers (DCWs), either certified nursing assistants in nursing homes (NHs) or personal care assistants in assisted living (AL), continues to be an unresolved problem. While numerous studies have examined predictors of DCW retention in NHs, little attention has been paid to differences between settings of long-term care. This study compares the predictors of DCW retention rates across both settings.

RESEARCH DESIGN AND METHODS

The 2017 Ohio Biennial Survey of Long-Term Care Facilities provides facility-level information from NHs and ALs (NHs = 739; ALs = 465). We compare the factors that predict retention rates of DCWs utilizing regression analysis. The factors are structural, financial, resident conditions, staffing, and management characteristics, as well as retention strategies.

RESULTS

Average DCW retention rates were 66% and 61% in ALs and NHs, respectively. Not-for-profit status was significantly associated with higher retention rates across settings. While the percent of residents with dementia and less administrator turnover were associated with significantly higher DCW retention in NHs, these were not significant for ALs. However, in the AL context, a higher county unemployment rate and DCWs' participation in resident care planning meetings were positively related to DCW retention after controlling for all other covariates, while DCW cross-training was negatively associated.

DISCUSSION AND IMPLICATIONS

Retention strategies for DCWs may need to differ by setting, as a result of differing working environments, resources, and regulations.

Federal requirements for nursing homes to include certified nursing assistants in resident care planning and interdisciplinary teams: A policy analysis

Starting in 2016, Centers for Medicare and Medicaid Services implemented the first phase of a 3-year multi-phase plan revising the manner in which nursing homes are regulated. In this revision, attention was placed on the importance of certified nursing assistants (CNAs) to resident care and the need to empower these frontline workers. Phase II mandates that CNAs be included as members of the nursing home interdisciplinary team that develops care plans for the resident that are person-centered and comprehensive and reviews and revises these care plans after each resident assessment. While these efforts are laudable, there are no direct guidelines for how to integrate CNAs in the interdisciplinary team. We recommend the inclusion of direct guidelines, in which this policy revision clarifies the expected contributions from CNAs, their responsibilities, their role as members of the interdisciplinary team, and the expected patterns of communication between CNAs and other members of the interdisciplinary team.