With so much of the nursing home staffing spotlight honed lately on increasing staffing levels, new study results emphasize the importance of experienced nurse and administrator retention as perhaps equally important for providing quality care.

“Given the recently announced federal minimum staffing mandates, there is a lot of policy focus at the moment on boosting the number of staff hours per president day. But our results suggest that we should also be giving similar weight to finding ways to retain staff and reduce turnover in an effort to improve nursing home quality,” said study co-author Brian McGarry, PhD, of the Division of Geriatrics and Aging, in the Department of Medicine at the University of Rochester.

Findings were released Monday morning in JAMA Internal Medicine and improve upon earlier studies, said study co-author Karen Shen (pictured), PhD, Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health. That’s partly because the new study gauges same-facility staffing and retention data over different points in time. 

The cross-sectional study considered 1.45 million facility-weeks of staffing levels involving 13,826 unique facilities, from April 2017 to December 2019. 

From that, 23,000 facility health inspections were observed. The average number of citations per facility was 6. A 10 percentage point increase in nurse staff turnover was associated with a 4% increase in citations and a roughly 2% increase in the rate of residents experiencing declines in mobility and independence with activities of daily living.

Investigators consulted CMS Payroll-Based Journal data to reach their findings. They said that during an average facility-week, 15.0% of nursing staff and 11.6% of administrators were new hires due to recent turnover. 

“The magnitude of … turnover effects are generally similar to the magnitude of the staffing level effects, suggesting that policies that monitor or reward facilities for lower staff turnover may be effective in improving quality of care,” Shen explained.

Employing staff who have lengthy, existing relationships with patients matters more than many, may realize, she added. That’s particularly true when it comes to ADL and mobility scores, which the research team identified as the most  “turnover-sensitive.” 

Important next steps

McGarry said he was most surprised by the strong association between turnover and quality of care. The effects of turnover are “multidimensional,” something operators and policy makers should remember with the proposed federal staffing mandate in play, he added.

“This study suggests we should be thinking about staffing consistency and retention just as much as overall staffing levels,” McGarry said. “To that end, [the Centers for Medicare & Medicaid Services] should be commended for adding staff turnover as a component of the Five-Star quality score on Nursing Home Compare.

“What’s more, I think it will be important to monitor turnover rates when the (federal staffing) mandate goes into effect,” he added. “It is certainly possible that a drive to meet staffing minimums with more temporary or contract-based staff could increase overall turnover rates in nursing homes.”

Researchers specifically examined turnover rates in periods before facility surveys, and how employees hired during the previous three months impacted subsequent citation rates. Ashvin D. Gandhi, PhD, of the UCLA Anderson School of Management, filled out the research team.

Our findings suggest that there may be harms even from losing mid-experience staff and replacing them with staff with no experience,” Shen said.

She offered that regulators and policymakers have several options to improve retention, such as including Medicaid or Medicare wage pass-through requirements (which require that a specified portion of reimbursement rate increases go toward increased staff wages); supplemental payments for the use of longer-tenured staff; funding for continued education and training for staff; and increasing the prominence of staff tenure and experience in Nursing Home Compare. 

She also called for nursing home operators and managers to “lend their own insight into the aspects of quality care that are turnover-sensitive” to try to figure out how to reduce turnover or limit its effect on quality of care.