Why Turnover in Nursing Home Staff Matters

Although prior research on factors impacting quality indicators of resident outcomes in nursing homes has focused on nursing home staffing and skill mix, less attention has been paid to the potential impact of staff turnover. A recent study used data from the National Nursing Home Survey to determine the impact of nursing staff turnover on residents. Even when staffing mix, bed size, and ownership were taken into account, higher turnover among certified nursing assistants was associated with significantly higher odds of a number of negative medical outcomes.

Based on the national data examined, the researchers estimated that there was an average annual turnover rate of 65 percent for CNAs and 47 percent for licensed nurses in US nursing homes. On average, 34 percent of the nursing staff were licensed nurses. Both CNA and licensed nurse turnover was higher in for-profit nursing homes compared to not-for-profits.

Compared to nursing homes with low CNA turnover, facilities with high turnover had significantly higher rates of pressure ulcers, pain, and urinary tract infections among residents. This relationship remained even after statistically controlling for the potential impact of nurse staffing and skill mix, bed size, and type of ownership. For licensed nurses, higher turnover was associated with twice the risk of high-risk pressure ulcers in the preliminary analysis, but unlike the outcomes for CNA turnover, this no longer became significant once staffing, skill mix, bed size, and ownership were taken into account.

In their discussion of these findings, the authors note that many studies have found that a higher proportion of licensed nurses improves care, and they propose that the higher turnover among CNAs—and that turnover’s impact on outcomes—may be part of why a higher ratio of licensed nurses has been associated with better resident outcomes. They also suggest that although a nursing home may appear to have adequate staffing on paper, “high turnover and related decreases in staffing stability could increase the complement of inexperienced personnel, hindering the quality care environments in [nursing homes].”

These findings led the authors to conclude that “turnover may be more important in explaining nursing home outcomes than staffing and skill mix and should therefore be given greater emphasis.” In order to address turnover problems, the authors suggest that both CNA pay and the work environment should be addressed. In terms of pay, the authors suggest that some of the additional cost to a nursing home could be offset by cost savings from the lower incidence of often expensive medical treatment. In particular, treatment for pressure ulcers can range from $2,000 to over $20,000. In the work environment, other research has found that having consistent resident assignments for staff can lead to a decline in turnover rates.


Trinkoff AM, Han K, Storr CL, et al. Turnover, staffing, skill mix, and resident outcomes in a national sample of US nursing homes. Journal of Nursing Administration (2013); 43(12): 630–636.


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