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Understanding Nurse Turnover in Long-Term Care Facilities

The turnover rate among nurses in long-term care is dire. A recent study using payroll-based daily staffing data from 15,645 facilities in the United States reported a mean and median annual turnover of 128% and 94%, respectively (Gandhi et al., 2021). In that same study, the RN turnover rate in long-term care facilities was 56.2% compared to 53.6% for licensed practical nurses (Gandhi et al., 2021). This data reflected pre-covid nurse turnover levels in long-term care facilities as it was gathered between October 2016 and March 2019. With the current staffing trends in the healthcare industry, it is logical to presume that these rates could even be higher post covid. High turnover among long-term care nursing staff results in poor quality care (Castle & Engberg, 2005), a higher number of survey deficiencies in nursing homes (Lerner et al., 2014), and workload increase for staff who remain in long-term care, low staff morale, and burnout.

Several nursing homes are closing their doors because of staffing shortages. Unfortunately, these closures will further widen the gap in healthcare access and equity among the vulnerable in our communities. Therefore, it is imperative to take a closer look into the issue of nurse turnover in long-term care.

Reasons Why Long-term Care Nurses Leave their Jobs

Many reasons influence the decision of long-term care nurses to leave their jobs. These are workload, disruptive workflow, inefficient work processes, poor leadership and management, low wages and salaries, and insufficient development and career opportunities.

Workload

The long-term care nurse’s daily workload is untenable. I recently put together a checklist of long-term care nurses’ daily tasks to ensure safe care that meets regulatory compliance. The list, on average, had 40 task items per shift, including the medication pass as one item. Many of these tasks involved multiple steps in completing. For example, achieving an accurate medication pass for 30 residents requires a minimum of 150 total steps. A study on time management found that a medication pass took an average of five minutes to complete per resident and a minute longer if the resident had dementia (Chen et al., 2021). The duties are further complicated with regulatory requirements. Suppose a facility gets cited for a deficient practice, in that case, there is a reactive response, and changes are made to the nurse’s work process. Usually, this will mean additional documentation, causing an added burden on the nurse. Despite these circumstances, the nurses manage to do their work and provide quality care. Bowers et al. (2001) studied how nurses manage time and their work in long-term care facilities and found that they utilized several strategies. They maximized their work efficiency by maintaining a routine, prioritizing and reprioritizing work, creating new time when the time was short, changing the sequence of tasks, minimizing time spent doing required work, and sometimes changing their work responsibilities. Doing what they considered “must-do” work and leaving other pertinent tasks undone (Bowers et al., 2001). Despite the joggling, the nurse is expected to take their lunch break, which is often unpaid and leave on time to prevent working overtime.

Workflow and Work Processes

Ironically long-term care facilities are transitioning to electronic health systems (EHR) to improve work processes, minimize medication errors and improve the overall work efficiency of their nursing staff. Yet, despite their good intentions, many have created work environments that are burdensome and untenable to the nurses they seek to help.

Many facilities do not provide a comprehensive all-in-one system due to either cost or incompatibility of merging systems, among others. For example, a facility may have a separate laboratory, pharmacy, and educational systems that are not integrated into their primary EHR. As a result, the nurses may have to log into multiple systems to retrieve vital information to complete their tasks. The disruptions this causes to the workflow are underestimated. Aside from these disruptions, other expected but unforeseen resident events occur, such as significant changes in condition, falls, and resident-to-resident altercations that may ultimately disrupt a nurse’s workflow.

Due to budget constraints, long-term care facilities often do not provide a unit secretary to answer phone calls on the unit or do other administrative tasks. Instead, the unit staff, including the nurse, is expected to answer the telephone. The telephone rings off the hook on the 7-3 shift and 3-11 shifts, and nurses must promptly attend to the phones and complete their medication pass without any errors. On the other side of the phone, the family member is often a disgruntled customer, compounding their stressors. It is not surprising that nurses usually dread to pick up phone calls because it disrupts their workflow and can make their day more stressful. Sometimes the phone call may be coming from the attending clinician looking for information on resident care.

Long-term care nurses also work with residents with psychiatric and other cognitive impairments who often exhibit behavioral dysfunctions that the nurse must manage. These actions further cause disruptions in their workflow and processes. In dealing with such resident populations, long-term care nurses also worry about navigating the delicate balance of behavior management and abuse, given that residents’ rights are paramount.

Leadership and Management

Leadership practices and administrator turnover significantly impact long-term care nurses’ turnover (Chu et al., 2013). Several facilities are struggling to maintain stability among their leadership. Directors of Nursing may stay less than a year on a job. This instability disrupts the organizational structures and places an emotional burden on the nurses, who often feel lost and unsupported.

The type of leadership practiced in a facility can profoundly affect staff morale. For example, a leader who believes in delegating tasks may do better in a larger facility than in a smaller facility. Staff in smaller facilities often view leaders who delegate tasks as insensitive to their needs due to their heavier workload and may develop animosity towards the leader. On the other hand, the staff often welcomes a hands-on approach.

Leaders that take a differential approach to discipline also create undue burden and stress on their nurses. In an environment where the workload is heavy, nurses expect their peers to perform their job roles and want to see peers they perceive as underperforming be addressed accordingly. If such expectations go unmet, it results in discontent and anger over time.

Leaders must have emotional intelligence (EI) and good communication skills to lead successfully. Their EI should reflect the work demands they place on their staff. Long-term care nurses feel emotionally distraught when they perceive management to make decisions or demands that lack empathy or sensitivity to their work.

The regulatory demands of the Center for Medicare and Medicaid Services (CMS) and the Department of Public health (DPH) place on long-term care facilities largely influence the work demands leaders place on their unit staff.

Wages and Salaries

Wages and salaries significantly impact a nurse’s decision to stay on a job. Considering the work demands of the long-term care nurse, it goes without saying that they must be compensated appropriately. Compared to a registered nurse wage in acute care, the long-term care registered nurse wage is minimal. In the past, it could be argued that skills needed to work in a long-term care facility were minimal compared to working in the hospital. This argument is not valid now since nurses in long-term care settings also manage complex disease processes. A subacute unit in some long-term care settings may be comparable to a medical-surgical unit in a hospital. The poor wages, among others, have resulted in the recent drive of nurses to move to agencies that offer higher wages for the same amount of work. It is ironic how long-term care corporations are willing to pay high agency wages but often reluctant to increase the wages of their dedicated staff.

Staff Development and Career Opportunities

The development of staff through education and training does not only improve the quality of care and competence of staff in carrying out work tasks. It empowers staff and makes them feel valued and committed to an organization. I am not referring to making quickly written notices and having staff sign for regulatory compliance. Instead, staff development establishes a continuing education program for staff relevant to their career growth and practice. Many long-term care facilities have adopted online education models that staff are expected to complete each quarter and annually. Though laudable, the implementation of such programs has many setbacks. For example, some facilities insist that staff complete their assigned education modules during work hours. Considering the workload and inefficient work processes that long-term nurses must navigate during a work shift, such policies can be burdensome for the nurse resulting in poor compliance and adding to the stressors of the nurse.

Furthermore, facilities do not have dedicated computer labs rooms that create a desirable environment for learning. In-person training, live webinars, and other interactive modes of instruction must be re-introduced since they present excellent relationship-building opportunities, which are much needed for staff retention.

Conclusion

The issue of nurse turnover is multifaceted. There is no one solution to prevent nurse turnover and improve staffing retention in long-term care settings. Having adequate funds can improve technology, wages, and some of the above problems. However, having worked in long-term care settings for almost 20 years, I can personally say that nurse retention is also about relationship building. Long-term care leaders must show empathy, build lasting relationships, and create a sense of community within their facility. Making your staff feel valued and respected goes a long way to have them stay even in a pandemic. The question is, how do we achieve that?

References

Bowers, B. J., Lauring, C., & Jacobson, N. (2001). How nurses manage time and work in long-term care. Journal of advanced nursing33(4), 484–491. https://doi.org/10.1046/j.1365-2648.2001.01686.x

Castle, N. G., & Engberg, J. (2005). Staff turnover and quality of care in nursing homes. Medical care43(6), 616–626. https://doi.org/10.1097/01.mlr.0000163661.67170.b9

Chen, E., Bell, J. S., Ilomäki, J., Corlis, M., Hogan, M. E., Caporale, T., Van Emden, J., Westbrook, J. I., Hilmer, S. N., & Sluggett, J. K. (2021). Medication administration in Australian residential aged care: A time-and-motion study. Journal of evaluation in clinical practice27(1), 103–110. https://doi.org/10.1111/jep.13393

Chu, C. H., Wodchis, W. P., & McGilton, K. S. (2014). Turnover of regulated nurses in long-term care facilities. Journal of nursing management22(5), 553–562. https://doi.org/10.1111/jonm.12031

Gandhi, A., Yu, H., & Grabowski, D. C. (2021). High Nursing Staff Turnover in Nursing Homes Offers Important Quality Information. Health affairs (Project Hope)40(3), 384–391. https://doi.org/10.1377/hlthaff.2020.00957

Lerner, N. B., Johantgen, M., Trinkoff, A. M., Storr, C. L., & Han, K. (2014). Are nursing home survey deficiencies higher in facilities with greater staff turnover. Journal of the American Medical Directors Association15(2), 102–107. https://doi.org/10.1016/j.jamda.2013.09.003

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