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Staff Retention and the Effect on Long-term Care Performance

Posted by Erin Pietrak | Saturday, May 06, 2017

The world of long-term care is changing at an increasingly rapid pace. Medicaid funding for home care has been increased, at the expense of long-term care funding, in order to avoid a monumental economic shortfall in senior health care. This has resulted in older, more acute seniors transferring to our long-term care facilities for shorter periods of time. Concurrently, an economic upturn has made recruiting and retaining care staff more difficult as the traditional pool of direct care workers we draw from find higher paying, less stressful jobs in other industries. This has several detrimental effects on our facilities’ staff, from administrators to direct caregivers, and has decreased resident quality of life. Historically, it was believed that staff shortages — nurse shortages especially — was the cause of decreased resident quality of life. But recent research has found that it is staff turnover, increase in agency staff use, lack of staff experience, ineffective training, and subpar care organization and management that cause poor care performance.[1]

The true costs of turnover are underestimated. The total costs of turnover are not seen on line items of our facilities’ financial statements, and are severely underestimated economically. For example, a facility with 200 CNAs and a turnover rate of 50% will lose about $350,000, but only a portion of that will show up as turnover; some of it will be seen as overbudgeted labor expense, while another portion will be seen in recruitment expense. But the real cost of turnover remains hidden in expenses like treating later-stage bedsores and more frequent hospital admissions. Over the last several years, squeezed budgets and a decreasing labor pool have led to direct care workers working shorter shifts or double shifts, and administrators increasing the use of agency personnel — all of which contribute to ever increasing turnover rates. In some instances, as a response to the problems caused by registered nurse shortages (e.g., lack of staff and resulting higher wages), some facilities have attempted to substitute LPNs for RNs wherever practical. Research shows this strategy will likely result in a greater number of resident falls, increased tube feeding, increased numbers of residents with deteriorated range of motion, and increased aggressive resident behavior.[2] In another study, decreased use of RNs was associated with higher instances of pressure ulcers in residents, as well as more frequent hospitalizations and UTIs.[3]

No organization, let alone a nursing home, will survive with the turnover rates that we are experiencing today. The Avila Institute of Gerontology recognizes this fact, and proposes that cohesive and collaborative teams play an instrumental role in improving staff turnover and, therefore, the quality of care provided to our elders. We are committed to designing programs that not only equip staff with the latest information on aging concepts, but also assist in developing mission-oriented (as opposed to wholly task-oriented) staff who are comfortable implementing the knowledge they obtain through our educational offerings. We anticipate that our multifaceted approach, which utilizes both traditional (e.g., face-to-face) and emerging (e.g., e-learning, virtual classrooms) training techniques, will reinforce the education that we provide more effectively than would relying exclusively on one technique. 

Collaboration is essential in order for any organization to thrive — nursing homes included. The importance of implementing collaborative training techniques can be seen when examining the efficacy of e-learning. While e-learning can be effective for strengthening individual skills, it appears to fall short when it comes to strengthening team skills. Building teamwork can result in “increased CNA empowerment; better CNA performance; improved resident care and choices; improved procedures, coordination, and cooperation between CNAs and nurses; and possibly reduced turnover.”[4] Research also demonstrates that, while individual skill training provided by e-learning may comply with auditor needs, it alone will not result in benefits of quality of care or reduced turnover. An omnibus study on staff dementia care training found that

educational interventions are more effective and sustainable when combined with additional supportive features/measures. Establishing a feedback culture ensures that communication becomes and remains a major topic within the facility in question. Training clinical nurses to provide feedback to nursing aides thus seems to be as important as the intervention itself. However, communication skills training must not be conceived as a single dose but should be followed by refresher or periodic “booster” sessions to assist staff with continuing to implement new skills… Without such follow up measures, effects will not be maintained when the researchers are gone. While many care staff members have high levels of knowledge and skills, they need help, support, and structures to develop and improve these skills…There is a strong need for an organizational framework that is supportive of communication as a crucial part of care and to facilitate changes in communication.[5]

Research also shows that providing training beyond that required by auditors can improve the employee work environment and reduce turnover. “Certified nursing assistants with additional initial training were more likely to report that their training was of high quality, and this was related to job satisfaction. Job satisfaction was also associated with receiving more training that focused on work life skills.”[6] Great teams require great leaders. Based on our research and experience, providing supervisors with the right education to lead will ultimately result in higher retention rates. We are in the process of augmenting our curricula to provide a solution to the concerns presented above, and are developing additional tools to complement the training that we provide. We have begun to see the fruits of our Palliative Care Curriculum, Dementia Curriculum, and Behavior Program, and look forward to sharing additional resources, as well as the results of our initiative, in the following months.

What kind of challenges or successes have you experienced with staff retention and education? Leave a comment below.


  1. Spilsbury K, Hewitt C, Stirk L, Bowman C.; The relationship between nurse staffing and quality of care in nursing homes: a systematic review; International J Nurs Stud. 2011 Jun;48(6):732-50
  2. Dwyer D; Experiences of registered nurses as managers and leaders in residential aged care facilities: a systematic review; Int J Evid Based Healthc. 2011 Dec;9(4):388-402.
  3. Horn SD; The business case for nursing in long-term care; Policy Polit Nurs Pract. 2008 May; 9(2):88-93.
  4. Yeatts DE, Cready CM; Consequences of empowered CNA teams in nursing home settings: a longitudinal assessment; Gerontologist. 2007 Jun;47(3):323-39
  5. Eggenberger, Eva, Katharina Heimerl, and Michael I. Bennett. "Communication skills training in dementia care: a systematic review of effectiveness, training content, and didactic methods in different care settings." International Psychogeriatrics 25.03 (2013): 345-358
  6. Han, Kihye, et al. "Associations between state regulations, training length, perceived quality and job satisfaction among certified nursing assistants: Cross-sectional secondary data analysis." International journal of nursing studies 51.8 (2014): 1135-1141.