The Relationships Among Licensed Nurse Turnover, Retention, and Rehospitalization of Nursing Home Residents

After acute hospitalization, many older medically complex patients are often discharged directly from intensive care units to receive postacute care in nursing homes (NHs). This skilled nursing care accounts for more than $20 billion in Medicare costs annually (Centers for Medicare & Medicaid Services, 2010). In order for Medicare beneficiaries to be qualified for skilled nursing facility (SNF) benefits, they should have been hospitalized for at least three days and require daily skilled nursing or rehabilitative services. Therefore, many post acute NH patients need treatments more sensitive to and contingent on the skilled care provided by the professional nurses (registered nurses [RN] and licensed professional nurses). Recent reports indicate that approximately one fourth of Medicare SNF patients are readmitted to the hospital within 30 days (MedPAC [Medicare Payment Advisory Commission], 2006; Mor, Intrator, Feng, & Grabowski, 2010). Although rehospitalizations are often necessary, previous research has estimated that approximately 28% to 40% of hospital readmissions might be avoided with high-quality SNF care (MedPAC, 2006; Saliba et al., 2000). In order to prevent rehospitalization of these Medicare beneficiaries receiving postacute care in SNFs, appropriate follow-up care is needed, and a higher professional nurse staffing level increases the capacity of NHs to care for these clinically complex residents (Decker, 2006; Kramer & Fish, 2001). Licensed nurses in NHs consist of RNs and licensed practical nurses (LPNs). The RNs primary roles are to assess resident health, develop treatment plans, and supervise LPNs and other direct care staff. LPNs in NHs provide direct patient care that includes taking vital signs and administering medications. Although LPNs scope of practice is more limited than that of RNs, studies have shown that LPNs often provide more hours of nursing care per day than RNs (Harrington et al., 2008). Licensed nurses in NHs are important in preventing rehospitalizations as, collectively, they conduct resident assessments, monitor changes in status, interact with family members, and contact physicians regarding significant changes (Decker, 2006). Research has indicated that licensed nurses’ clinical care knowledge, care coordination, and professional oversight contribute to better quality of care in NHs (Castle & Anderson, 2011), and higher RN staffing levels as well as the ratio of skilled to unskilled nurses have been linked to fewer postacute rehospitalizations (Decker, 2008; Intrator et al., 2007; Intrator, Zinn, & Mor, 2004). It is believed that a stable set of nursing personnel is more likely to deliver better care. Furthermore, several literatures have repeatedly shown that high staff turnover rates are associated with poor quality of care (Bostick, Rantz, Flesner, & Riggs, 2006; Castle & Engberg, 2005; Horn et al., 2010; Zimmerman, Gruber-Baldini, Hebel, Sloane, & Magaziner, 2002). High staff turnover, particularly among licensed nurses, may make it difficult to assess residents and implement care plans, may reduce familiarity between staff and residents, making detection of complications and failing health more difficult, and may affect quality through insufficient supervision and training. Higher licensed nurse turnover has been found to be associated with activities of daily living (ADLs) decline (Horn et al., 2010), and the RN turnover has been found to be associated with infections and hospitalization (Zimmerman et al., 2002). However, some have suggested that some turnover is not necessarily detrimental to the organization (Alexander, Bloom, & Nuchols, 1994; Brannon, Zinn, Mor, & Davis, 2002; Halbur & Fears, 1986), and others have found that the relationship between licensed nurse turnover and quality is not linear (Castle, Engberg, & Men, 2007; Weech-Maldonado, Meret-Hanke, Neff, & Mor, 2004). Although much literature has been devoted to examining nursing staff turnover, often calculated as the number of terminations in 1 year divided by the total number of staff (Donoghue, 2010), less attention has been paid to NH’s proportions of licensed nurses with long periods of continuous service, or its retention of licensed nurse staff. Castle and Engberg (2008) found that RN stability (defined in their study as the percent of RNs with a tenure of 5 or more years at the facility) is associated with decreased physical restraint use, the prevalence of moderate to severe pain, pressure sores, and indwelling catheters. However, the relationship between licensed nurse retention and rehospitalization remains unknown. Retention, although a conceptually different measure of staff stability from turnover, has the same potential to influence care and reduce spending on hiring and training. The turnover calculation may reflect turnover for the same position and does not capture the number of employees who are experienced in their roles. Because facilities may not only have a high turnover rate but also have a high retention rate, it is important to investigate NHs’ “stayers” as they represent experienced staff who may contribute to better standards of care quality despite high turnover levels. “Stayers” are important to the NH as they hold the institutional memory, receive facility-specific training, retain knowledge and practice strategies, know the long-stay residents, implement facility-specific protocols, and make it possible to efficiently incorporate new staff into the existing culture and practice.