High Nursing Home Staff Turnover Yields Poorer Care Quality

Higher staff turnover in nursing homes was associated with lower care quality, a study published in JAMA Internal Medicine revealed.

Staff and administrator turnover in nursing homes can disrupt continuity of care and impede relationships between residents and staff. Recent regulations from CMS have focused on improving staffing levels in nursing homes, but the agency also started measuring turnover rates in 2022 through the Nursing Home Compare tool.

Researchers used CMS data on health inspection citations and quality measures at nursing homes and turnover measures from daily staffing payroll data to determine how staff turnover impacts care quality. The study sample included 1.45 million facility-weeks between April 1, 2017, and December 31, 2019, representing 13,826 nursing home facilities.

The turnover measure used in the study reflected the share of care being provided by newly hired staff. This measure was 15.0 percentage points for direct care nursing staff, indicating that in the average facility-week, 15.0 percent of nursing hours were provided by employees hired within the last 90 days. The average turnover measure was 11.6 percentage points for administrators.

Researchers assessed 22,956 health inspections for the nursing home in the study sample. States conduct these inspections unannounced and on a yearly basis. The mean number of citations among these inspections was 6.0. While most citations were for limited severity infractions, there were 2,770 citations of actual harm and 923 citations of immediate jeopardy. Nearly 20 percent of citations were quality-of-care citations.

The study found that increased nursing staff turnover was associated with decreased performance on health inspections. A 10-percentage point increase in nursing turnover was tied to an additional 0.241 citations in health inspections, signifying a 4.0 percent increase from the mean.

Higher nursing staff turnover was primarily associated with an increase in citations of potential harm rather than citations of no harm or immediate jeopardy.

Researchers also looked at quarterly quality measures for nursing homes gathered by CMS from resident assessments and claims data. A 10-percentage point increase in nursing staff turnover was associated with reductions in the composite assessment-based quality measure by 0.035 and the composite claims-based score by 0.020.

Increased staffing turnover had the strongest association with measures related to whether long-stay residents experienced a worsening of activities of daily living or mobility. A 10-percentage point increase in turnover correlated with a 0.29-percentage point increase in the share of residents experiencing worsening activities of daily living and a 0.35-percentage point increase for worsening mobility.

The COVID-19 pandemic exacerbated staffing challenges across all healthcare facilities, including nursing homes. Burnout, poor compensation, and inadequate training and support have contributed to high levels of staff turnover.

Policies that improve staff and administrator retention, such as additional payments for longer-tenured staff or funding for continued education and training, could help reduce turnover and boost care quality, researchers wrote.