Turnover of licensed nurses in skilled nursing facilities

Nursing Economics, March-April, 2002 by Teresa P. Thompson, Hazel N. Brown

Executive Summary

* Like hospitals, skilled nursing facilities (SNFs) face increasing cost and regulatory pressure, but they have also experienced greater turnover rates among staff and bear the brunt of the population growth among the elderly.

* The researchers examined the relationship between staff turnover and several other variables such as demographics about the DON, facility variables, and staffing patterns.

* The educational preparation and tenure of the DON, salaries, opportunities for advancement, for/not-for-profit status, and location did not have a significant relationship with turnover rates.

* The size of the facility showed a nearly significant relationship with turnover, with larger SNFs having higher turnover rates.

* DONs perceived that pay/benefits, work environment, and teamwork were factors in retention, while poor pay/benefits, schedule conflicts, and relocation were perceived as drivers of turnover.

* The authors noted DONs and administrators have the ability to control the majority of the perceived factors influencing retention and turnover.

ADVANCES IN DISEASE control and health care technology have dramatically increased the life expectancy for Americans. According to the U.S. Department of Commerce (1993), in the 1920s the average life expectancy was 54.1 years. By 1965, the figure had jumped to 70.2 years, and it is projected to be 77.6 years by the year 2010.

Current estimates indicate that there are approximately 16 million people in the United States over age 65. Projections for the year 2030 for this age group vary greatly: from 31 million (Knapp, 1997), to 64 million (Ross & Wright, 1998), to 70 million (U.S. Department of Commerce, 1993).

As more of this group live longer, there will be a growing number of frail, chronically ill, elderly people in need of health care. Currently, less than 5% of the elderly population reside in nursing homes or skilled nursing facilities (SNFs). However, approximately 25% will spend some time in a SNF during the last years of life (Swanson & Tripp-Reimer, 1997). Because of the unprecedented number of people who are living longer, there will be dramatic increases in the number of persons utilizing SNFs (Ross & Wright, 1998).

SNFs now provide complex treatments and therapies for geriatric patients including intravenous therapy (IV therapy), peritoneal dialysis, tracheostomy care, and respirator care. SNFs have not provided this kind of acute care in the past, and they are struggling to meet these demands for a growing patient population. In addition, regulatory and financial restrictions are forcing administrators to push the nursing staff to "do more with less."

As a result SNFs typically have higher nursing turnover rates than hospitals and other settings where nurses are employed (Mesirow, Klopp, & Olson, 1998). According to Cohen-Mansfield (1997), turnover among nursing staff in SNFs ranges from 40% to 75%, and can go as high as 500%. According to R. Jenkins, director of policy development, North Carolina Health Care Facility Association, in 1997 SNF turnover rates in North Carolina were as follows: registered nurses (RNs) = 71%, licensed practical nurses (LPNs) = 53%, and nursing assistants (NAs) = 99% (personal communication, February 3, 1999). Compounding the turnover problem facing SNFs is the fact that we are now facing a nursing shortage that will only worsen with the turn of the century (Curtin, 1998). As the population ages, their use of SNFs increases and patient acuity in SNFs increases. It is clear that there is a crisis with staffing in SNFs.

The costs (both direct and indirect) of turnover have been studied by many researchers in both acute and nonacute settings. The cost to replace a RN in an outpatient setting was estimated by Bame (1993) to be more than $10,000. According to Jones (1990), the cost to replace a RN employed in a hospital is also over $10,000. Caudill and Patrick (1991) noted that replacing an RN in a SNF could cost over $7,000. Given the scarce resources available in SNFs, the cost of replacing RNs in a SNF can spell disaster.

Little research has examined the turnover of licensed nurses in SNFs. However, several studies have examined turnover of certified nurse assistants (CNAs) and some of the reasons for CNA turnover in SNFs might be the same for the turnover of licensed nurses in SNFs. Mesirow et al. (1998) found that meeting CNA's security needs resulted in decreased turnover. They also found that increasing involvement in patient care and in work life decisions positively affected employee satisfaction and reduced turnover. Brannon, Cohn, and Smyer (1990) and Helmer, Olson, and Heim (1993) found that CNA turnover in SNFs was related to dissatisfaction with salary. Caudill and Patrick (1989) found a relationship between CNA turnover and salary, benefits, and feedback from residents, peers, and staff. And Holtz (1982) found that interpersonal relationships positively affected work satisfaction and turnover among CNAs in SNFs.