Prioritizing Nursing Home Staff and Leadership Consistency to Improve Quality

People who receive care in nursing homes are there due to a combination of cognitive deficits, functional impairments and serious medical illness. Nursing home residents, and their family members, expect that needed care will be delivered “hands on,” through the support of attentive, well-trained staff. The skill sets of clinicians, in particular RNs trained in assessment who can support the medical needs of residents, is critical. Most of the hands on care – helping people out of bed, to the bathroom, with their meals – is delivered by nursing aides. The front-line clinical staff, in turn, needs a supportive work environment led by the administrator of the facility. Thus, there is face validity to the premise that consistent staff, and leadership, are better positioned to provide consistent quality care to nursing home residents. Unfortunately, the nursing home industry is plagued by high turnover rates for both clinical and administrative positions.^1,2 The recent National Academy of Sciences (NASEM) report on nursing home quality emphasizes the importance of studying turnover and identifying strategies to reduce turnover as a key recommendation.³ The work by Zheng et al in this issue provides further evidence that turnover in nursing homes is associated with measures of nursing home care quality and health care utilization.

Prior research has described the relationship of staffing levels to quality of care.^4,5 There has been less work focused on the relationship of quality to turnover and retention; although any person who has lived in, had a family member in, or worked in a nursing home will attest to the value of staff who have a consistent presence (and the frustrations that occur when staff cycle in and out). Consistent assignment for day to day clinical care is championed as a best practice, particularly for residents with dementia. This becomes impossible in a setting of high turnover and overall low staffing, when the focus is simply meeting the basic needs of residents or checking off boxes to meet facility tasks.

Administrator turnover can happen in a variety of circumstances and thus relationship to quality measures may be complicated. Talented administrators may leave due to promotion to a larger facility or a corporate position; conversely, administrators may lose their positions in the setting of falling quality ratings. Administrator turnover, however, can be at minimum disruptive to the culture of the facility, may prompt other staff to leave, and new administrators may need to recreate or re-organize processes. Administrator buy-in is needed to lead the charge on implementing innovative projects and programs. Such programs, which could target fall reduction, polypharmacy, adding palliative care programs, reducing avoidable hospital transfers, or any other quality improvement initiative, may fall by the wayside during a leadership transition.

Recruiting and retaining qualified staff is already the priority of most nursing home operators; the impact of the COVID-19 pandemic brought additional attention to this issue.⁶ Unfortunately, there is a dearth of approaches shown to impact staff retention in this setting. Researchers must partner with operators to further test and describe pragmatic and scalable retention strategies for nursing homes. Some researchers have found that retention can be improved by providing opportunities for career training and advancement, involving hands on staff in care planning, and other dedicated efforts aimed at retention and reflective of a culture that values staff input.^7–9 There is a need to further describe the best practices that can be implemented for successful staff retention. This can be achieved in part through support for more research into successful retention strategies coupled with policies that promote evidence-based retention strategies.

The urgency for retaining qualified, caring staff and administrators is keenly felt at the ground level of the nursing home industry. Facility level administrators need to be empowered, supported, and inspired to create cultures where clinical staff thrive. Policymakers at the federal and state levels should focus on designing incentives to recruit and retain staff in this high need setting. The finding that increased turnover is associated with increased, potentially avoidable, healthcare utilization supports an economic case to funnel funds towards retaining nursing home staff and administrators. Fundamentally, nursing home staff need fair compensation and benefit packages, as well as adequate training and support to do their work. The analyses by Zheng and colleagues, describing the associations of nursing home staff turnover and quality helps orient us all towards this vital work – we need to prioritize nurturing and supporting staff so that they can deliver the hands-on care nursing home residents require.