Retention Attention: A Close Look at Workforce Retention in Assisted Living & Nursing Homes

Research suggests higher retention of direct care workers is related to better care quality in nursing homes; however, retention rates are much lower in nursing and assisted living compared to other industries. One study explored characteristics that improve retention of direct care workers for each level of care.

Data from the 2017 Ohio Biennial Survey of Long-Term Care Facilities, combined with a few other sources, were used to find information on 739 nursing homes and 465 assisted living communities. The researchers examined how retention rate of direct care workers varied according to facility characteristics, such as number of beds, profit status, occupancy rate, ratio of staff to residents, and retention strategies.

Overall, the retention rate over one year was 61% for nursing homes and 66% for assisted living. In other words, nearly 40% of direct care workers had left their facility over the course of a year. For both nursing and assisted living, retention was significantly better for not-for-profit communities than for-profit communities. The size of the community, having a memory care unit, and occupancy rate were not related to retention.

Apart from profit-status, high staffing level and more residents with dementia were related to better direct care worker retention in nursing homes. For assisted living, retention was higher for facilities located in rural areas and in counties with high unemployment.

Interestingly, most retention strategies were not associated with higher retention. This included consistent assignment to the same resident, staff empowerment, choice of resident cared for, and financial incentives. Only direct care worker participation in care planning was associated with better retention for both nursing and assisted living. Cross-training was actually associated with poorer retention for assisted living.

Characteristics that influence retention were slightly different for nursing compared to assisted living, suggesting that one size does not fit all regarding retention efforts. This study was limited to communities in Ohio, which may partially explain differences from other studies. While retention should be a focus for most communities, those that are for-profit, urban/suburban, and located in low unemployment areas can expect higher turnover, while direct care planning is a useful retention tool.


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Kennedy KA, Applebaum R, Bowblis JR, and Straker JK. Organizational factors associated with retention of direct care workers: A comparison of nursing homes and assisted living facilities. The Gerontologist 2021; 61(4), 530-539.

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