Leadership Matters: Investigating the Association Between Nursing Home Administrator Turnover and Quality

BACKGROUND AND OBJECTIVES

Existing research has associated nursing home (NH) staff turnover with poor performance, yet the impact of nursing home administrator (NHA) turnover remains relatively understudied. This study aimed to explore the relationship between NHA turnover and NH quality, and to determine if this relationship was mediated by registered nurse (RN) turnover.

RESEARCH DESIGN AND METHODS

Utilizing data from multiple secondary sources, including the Care Compare: Skilled Nursing Facility Quality Reporting Program (SNF QRP) and LTCFocus.org, this study employed a longitudinal analysis covering the period 2021-2022 (n = 19,645). The dependent variable was quality star ratings from SNF QRP, whereas the independent variable was NHA turnover, reflecting the number of administrators who left each facility annually. We used Baron and Kenny's mediation testing method, incorporating 2-way fixed effects (state and year level) with appropriate organizational and market level control variables.

RESULTS

The results affirmed that NHA turnover negatively affected quality, decreasing the likelihood of a higher star rating by 14% with one departure and 25% with multiple departures (p = .001). Additionally, NHA turnover correlated with an increase in RN turnover by 7% and 11%, respectively, for one and multiple departures (p = .001). RN turnover fully mediated the impact of NHA turnover on quality, nullifying the direct effect of NHA turnover.

DISCUSSION AND IMPLICATIONS

The results of this study highlight the synergistic relationship between administrators and caregivers in NHs. To enhance NHA retention, NHs should improve compensation and benefits. Nonetheless, broader governmental support and interventions might be necessary to sustain these improvements.

Beyond the Balance Sheet: Investigating the Association Between NHA Turnover and Nursing Home Financial Performance

Introduction

Nursing homes (NHs) serve as a safety net for vulnerable populations such as older adults and people with disabilities. Nursing Home Administrators (NHAs) play a crucial role in managing the daily operations of NHs, including overseeing direct care staff and establishing the facility's strategic direction. Unfortunately, NHs have consistently faced high NHA turnover rates, which have been linked to poor organizational performance. This study aims to investigate the relationship between NHA turnover and financial performance in NHs.

Methods

Using an integrated perspective based on the upper echelons theory and the resource-based view of the firm, we investigated the association between NHA turnover and financial peformance using multiple secondary data sources, such as the Care Compare: Skilled Nursing Facility Quality Reporting Program and Brown University's Long Term Care Focus. We conducted a cross-sectional study using a multivariate linear regression model, measuring financial performance using operating margin while NHA turnover represents the number of administrators that left the organization.

Results

Our findings indicate that NHs with higher NHA turnover rates have lower operating margins. Specifically, compared to facilities with no turnover, one NHA turnover is associated with a 1.14% decrease in operating margin, and two or more turnovers are associated with a 2.25% decrease.

Discussion

This study contributes to the existing literature by demonstrating the financial impact of NHA turnover and provides further evidence of the need for targeted organizational and policy interventions to improve NHA retention.

The Impact of Wages on Care Home Quality in England

BACKGROUND AND OBJECTIVES

In many countries, a large proportion of long-term care staff are paid at, or near, minimum wage, leading to concerns of negative effects on care outcomes. This study analyzed the effect of staff wages on care home quality ratings in England.

RESEARCH DESIGN AND METHODS

A national staffing database of long-term care providers was matched with local-area information on needs and supply to construct a 3-year panel (2016-2018) of English care home observations. Using multiple imputation methods to address missing data provided a data set of 12,055 observations of 5,556 care facilities (both residential and nursing homes). We analyzed the effect of the facility-level average hourly wage of care staff on national regulator quality ratings. A measure of the impact of exogenous changes in the national minimum wage on care facilities was used as an instrument for wage.

RESULTS

We find that wages positively affect care home quality ratings. Other things equal, a 10% increase in the average hourly wage of direct care workers would lead to a 7.1% increase in the likelihood that a care home will have a high-quality rating. The wage effect on quality was significant when controlling for staff skill mix, measured as the share of registered nurses in nursing home staff.

DISCUSSION AND IMPLICATIONS

This study provides important evidence of the positive impact that staff pay can have on the quality of long-term care. Our finding has important implications for appropriate levels of pay and the funding of long-term care.

The Effect of Nurse Aide Retention on Ohio's Nursing Home Resident Care Experience Scores: A Facility-Level Analysis

This study examined whether certified nurse aide (CNA) retention was positively related to nursing home (NH) resident care experiences at the organizational-level. The 2017 Ohio Biennial Survey of Long-Term Care Facilities and the 2017 Ohio Nursing Home Resident Satisfaction Survey provided the key variables. Quartiles of CNA retention (0-48%, 49-60%, 61-72%, 73-100%) were created from the analysis sample (N = 667). Regression analyses clustered NHs within counties and controlled for structural characteristics, financial resources, empowered managers, resilience, quality of work-life, resident, and community characteristics. NHs in Quartile 3 of CNA retention had higher environment scores by 1.36 percentage points compared to Quartile 1 (p < .05). NHs in Quartile 4 had lower facility culture scores by 1.31 percentage points than NHs in Quartiles 1-3 (p < .05); this pattern repeated when Quartiles 3 and 4 were compared on other outcomes. Future research should explore NHs with very high CNA retention to improve understanding of the measure.

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.

The One-Two Punch of High Wages and Empowerment on CNA Retention

OBJECTIVES

The objective of this study was to examine the relationship between high wages and empowerment practices on certified nursing assistant (CNA) retention, necessary for providing high-quality care for nursing home (NH) residents.

METHODS

Measures of provider-level CNA empowerment and wages from the 2015 Ohio Biennial Survey were used to estimate two regression models on retention (n = 719), one without and one with an interaction term of high wages and high empowerment.

RESULTS

Only in the context of the interacted model were NHs that provided both high wages and high empowerment associated with a 7.09 percentage-point improvement in the CNA retention rate (p = .0003). Individually, high wages and a high empowerment score were not statistically significant in either regression model.

DISCUSSION

Retaining CNAs in NH communities requires a combination of empowerment practices (e.g., involving CNAs in decision-making about hiring other staff) and high hourly wages.

It Is Time to Resolve the Direct Care Workforce Crisis in Long-Term Care

Nearly 4.6 million direct care workers-including personal care aides, home health aides, and nursing assistants-provide daily support to older adults and people with disabilities across a range of settings in the United States, predominantly in long-term care (LTC). Even as the population grows older and drives up demand for LTC, the sector continues its decades-long struggle to fill direct care positions and stabilize this essential workforce. Recent events and emerging trends have converged, however, to produce new opportunities to address this longstanding workforce crisis, including the unprecedented attention generated by the coronavirus disease 2019 (COVID-19) pandemic and the systemic shifts to managed care and value-based payment in LTC. This Forum article outlines the pressing direct care workforce challenges in LTC before describing these potential levers of change, emphasizing the importance of not just expanding the workforce but also maximizing direct care workers' contributions to the delivery of high-quality services for a growing and evolving population of LTC consumers.

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.

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

BACKGROUND AND OBJECTIVES

Certified nursing assistant (CNA) turnover and retention are critical aspects of facilities' ability to provide cost-effective, high-quality person-centered care. Previous studies and industry practice often treat turnover and retention as similar concepts, assuming that low turnover and high retention are synonymous. The study addressed the question of whether turnover and retention rates differ and if so, what those differences mean for nursing home practice, policy, and research.

RESEARCH DESIGN AND METHODS

This study examines facility-level factors associated with CNA retention and turnover rates using 2015 data from the Ohio Biennial Survey of Long-Term Care Facilities, Ohio Medicaid Cost Reports, Certification and Survey Provider Enhanced Report, and the Area Health Resource File. Using bivariate tests and regression analysis, we compare rates and the factors associated with retention and turnover.

RESULTS

The mean facility annual retention rate was 64% and the mean annual turnover rate was 55%. As expected, there was a statistically significant and negative correlation between the rates (r = -0.26). However, some facilities had both high retention and high turnover and some had low rates for both measures. Not all the variables that are associated with turnover are also associated with retention.

DISCUSSION AND IMPLICATIONS

CNA retention is not simply the absence of CNA turnover. Given the differences, nursing homes may need to use strategies and policies designed to target a particular stability measure.

Assuring Quality in Nursing Homes: The Black Box of Administrative and Clinical Leadership—A Scoping Review

Background and Objectives

Licensed nursing home administrators (NHA) and directors of nursing (DON) are responsible for nursing home quality and assuring optimal performance and job satisfaction/retention of their nursing home workforce. NHA/DON-focused studies have generated important foundational knowledge over the last three decades; yet, targeted research is needed to understand and apply the complexities of the black box of this top management team. This scoping review identifies, reviews, synthesizes, and maps the topical areas of research in NHA/DON positions in U.S. nursing homes.

Research Design and Methods

We conducted searches of 5 databases, yielding 3,479 records; screening/review yielded 88 unique records. We used thematic analysis to code the primary foci of the studies and the variables associated with the concepts of interest.

Results

Most papers (n = 40) focused on role characteristics, 23 examined approaches to management and leadership, 24 focused on perceptions about the role, and the remaining 12 examined role structure. The role-related themes linked to outcomes (n = 42), processes (n = 27), and structures (n = 30).

Discussion and Implications

We highlight important gaps for future research and offer a call to action for research, policy, practice, and education collaborations to accelerate the rate of research and translate the findings into best practices for NHA/DON to lead and manage the nursing home workforce and build capacity to ensure person-centered, high-quality care. Based on foundational descriptive studies, it is time to use what is known to design and implement interventions that enhance the capacity of NHA/DON to improve the structures, processes, and outcomes of nursing homes.

Facilitators and Barriers Surrounding the Role of Administration in Employee Job Satisfaction in Long-Term Care Facilities: A Systematic Review

Previous literature has shown how associate engagement has positively impacted on productivity, job satisfaction, safety, retention, consumer sentiment, and financial performance in hospitals and healthcare systems. However, a lack of research showing the relationship between associate engagement and job satisfaction within the long-term care environment has existed. Our objective was to investigate characteristics within the long-term care environment that promote and detract from associate job satisfaction and extrapolate the best practices in maintaining job satisfaction and engagement. This systematic review queried CINAHL, PubMed (MEDLINE), and Academic Search Ultimate databases for peer-reviewed publications for facilitators and barriers commensurate with employee job satisfaction in long-term care facilities using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and the Kruse Protocols. The authors identified 11 facilitators for job satisfaction and 18 barriers to job satisfaction in the 60 selected articles. The top four facilitators were Supportive Leadership, Capable and Motivated Employees, Positive Organizational Values, and Social Support Mechanisms. The top four barriers were condescending management style, high job demands, lack of self-care, and lack of training with medically complex patients. The systematic review revealed the importance of maintaining satisfied employees in the long-term care workplace through am emphasis leadership and on the facilitators identified to best serve their associates and improve care for residents.

Is the Quality of Nursing Homes Countercyclical? Evidence From 2001 Through 2015

BACKGROUND AND OBJECTIVES

To examine whether nursing homes (NHs) provide better quality when unemployment rates rise (countercyclical) and explore mechanisms contributing to the relationship between quality and unemployment rates.

RESEARCH DESIGN AND METHODS

The study uses the data on privately owned, freestanding NHs in the continental United States that span a period from 2001 through 2015. The empirical analysis relies on panel fixed-effect regressions with the key independent variable being the county-level unemployment rate. NH quality is measured using deficiencies, outcomes, and care process measures. We also examine nursing staff levels, as well as employee turnover and retention.

RESULTS

NHs have better quality when unemployment rates increase. Higher unemployment rates are associated with fewer deficiencies and lower deficiency scores. This countercyclical relationship is also found among other quality measures. In terms of mechanisms, we find higher nursing staff levels, lower employee turnover, and better workforce retention when unemployment rates rise. Improvement in staffing is likely contributing to better quality during recessions. Interestingly, these effects predominately occur in for-profit NHs for deficiencies and staffing levels.

DISCUSSIONS AND IMPLICATIONS

NH quality is countercyclical. With near record-low unemployment rates in 2018, regulatory agencies should pay close attention to NH quality when and where the local economy registers strong growth. On the other hand, the finding of the unemployment rate-staffing/turnover relationship also suggests that policies increasing staffing and reducing employee turnover may not only improve NH quality but also have the potential to smooth quality fluctuations between business cycles.

Leadership, Staff Empowerment, and the Retention of Nursing Assistants: Findings From a Survey of U.S. Nursing Homes

OBJECTIVES

We examined the relationship between nursing assistant (NA) retention and a measure capturing nursing home leadership and staff empowerment.

DESIGN

Cross-sectional study using nationally representative survey data.

SETTING AND PARTICIPANTS

Data from the Nursing Home Culture Change 2016-2017 Survey with nursing home administrator respondents (N = 1386) were merged with facility-level indicators.

METHODS

The leadership and staff empowerment practice score is an index derived from responses to 23 survey items and categorized as low, medium, and high. Multinomial logistic regression weighted for sample design and to address culture-change selection bias identified factors associated with 4 categories of 1-year NA retention: 0% to 50%, 51% to 75%, 76% to 90%, and 91% to 100%.

RESULTS

In an adjusted model, greater leadership and staff empowerment levels were consistently associated with high (76%-90% and 91%-100%) relative to low (0%-50%) NA retention. Occupancy rate, chain status, licensed practical nurse and certified nursing assistant hours per day per resident, nursing home administrator turnover, and the presence of a union were also significantly associated with higher categories of retention (vs low retention).

CONCLUSIONS AND IMPLICATIONS

Modifiable leadership and staff empowerment practices are associated with NA retention. Associations are most significant when examining the highest practice scores and retention categories. Nursing homes seeking to improve NA retention might look to leadership and staff empowerment practice changes common to culture change.