The elevated nurse turnover rate in long-term care facilities poses a substantial challenge to the quality and accessibility of healthcare services. This situation has worsened due to the impacts of the COVID-19 pandemic, highlighting the urgent need to tackle nurse retention issues within these environments. Our course will delve into the pressing matter of nurse turnover in long-term care, applying a community integration model aimed at bolstering nurse resilience, fostering a sense of belonging, boosting job satisfaction, and ultimately enhancing retention rates and the quality of care.

1. Introduction

• Overview of the high nurse turnover rates in long-term care facilities
  • High nursing staff turnover in nursing homes is associated with higher mortality. 
  • Increased number of deficiency citations. 
  • Increased likelihood of infection control citation.
  • nurse turnover in NHs relates to the use of antipsychotic medications. 
  • High nurse turnover in NHs leads to substantial costs, such as recruitment and training for new nursing staff. 
• Exploration of contributing factors to nurse turnover
  • Organizational factors
  • Individual factors
  • Affective Sentiments
  • Relationship and Supports 
• Importance of community integration in the workplace
  • Foster a sense of belonging.
  • Enhance organizational citizenship behavior.
  • Foster job satisfaction
  • Promote staff resilience 
  • Improve nurse retention. 

1. Theoretical Framework- Community Integration Model 

• Introduction to the model and its components
  • Transition Phase
    • Fear
    • Anxiety
    • Anticipation
    • Excitement
    • Vulnerability
  • Adjustment Phase (0-3months)
    • Orienting to the new environment 
    • Building trust
    • Becoming self-aware 
      • “Transition shock”
    • Forming perceptions 
    • Beginning new relationships 
  • Adjustment supports.
    • Welcoming and inclusive Environment
    • Effective onboarding and comprehensive Orientation
    • Mentorship and Preceptorship
    • Effective communication
    • Team collaboration and camaraderie
    • Emotionally intelligent leadership (Compassion and empathy) 
    • Supportive Supervision
    • Opportunities for emotional support for stressful situations
    • Adequate resources 
    • Fair financial remuneration
  • Social Integration Phase (3-6months)
    • Strengthening relationships
    • Increasing participation in the workplace
    • Improved job competence
    • Increasing productivity
  • Social Integration supports.
    • Maintain an Inclusive and safe work environment. 
    • Shared governance- e.g. Participation in QAPI
    • Social events (e.g., staff retreat with stress-relieving activities, etc.)
    • Effective leadership 
    • Effective Communication
    • Support for Work-Life Balance
    • Recognition and Feedback
    • Maintain efficient systems
    • Maintain adequate resources 
    • Cultural competence and diversity training
    • Workload management
    • Staff development (Continuous education and competencies)

• Community Integration Phase (6-12 months)
  • Independence
  • Role mastery
  • Increased productivity 

• Community integration supports.
  • Career development
  • Recognition and appreciation 
  • Celebration of Milestones
  • Continuing education and competency training 
  • Foster professional autonomy
  • Maintain a flexible work schedule. 
  • Employee perceptions
  • Healthy work environment 
  • Access to employee assistance programs
  • Continuing education 
  • Review Compensation 

• Barriers to Integration
  • Lack of supports and resources.
  • Poor leadership
  • Workload 
  • Financial barriers (Low wages)
  • Environmental barriers (organizational barriers) 
  • Marginalization
  • Bullying
  • Incivility
  • Racism

• A Practical Application of CI Model to a structured orientation program for Long-term care nurses
  •  General onboarding
  • Didactic (7-days)
  • Clinical emersion (5-days)- Patient and Task Layered Approach 
    • Day 1 – Preceptor led
    •  10 residents- Assessment and documentation – level 1
    • Day 2- Preceptor led
    • 10 residents – Level 1 task + medication and treatment administration- level 2
    • Day 3- Preceptor led
    • 15 residents- level 1 and 2 tasks + communication and family engagement- level 3
    • Day 4- Preceptor assist
    • 20 residents- level 1,2,3 tasks + safety & quality – level 4
    • Day 5 – new hire led/preceptor assist
    • Full load assignment- level 1,2,3,4 tasks + continuum of care (acute transfer, discharges, admissions)
  • Trained preceptorship
    • Recruit preceptors (offer an incentive to precept)*
    • Role training and expectation
    • Communication and feedback 
    • Methods of evaluation (Use of standard evaluation tool)
    • Documentation 
    • Provide supportive supervision. 
  • Continual Mentorship
    • Weekly one-on-one check-in sessions
    • Weekly goal setting and review
    • Self-care
    • Relationship building 
    • Supportive leadership
  • Continual education (Monthly)
    • Include team-building activities.
    • Opportunities for socialization
  • Monthly staff meeting
    • Foster relationship building (Social Integration)
    • Self-care activities 
    • Interactive discussions
    • Problem-solving (Team approach) 
  •  Maintain a healthy work environment. 
    • Continual education 
    • (Team building- creating opportunities for engagement and socialization)
    • Cultural/ diversity training
    • Workload management
    • Time management training
    • Effective communication 
    • Managing workplace incivility, bullying, and violence 
    • Enhance general regulatory compliance.
    • Shared governance
    • Flexible work schedule
    • Communication/suggestion box
  • End of program evaluation 
    • Weekly preceptor evaluation
    • Skills competency checklist 
    • Comprehensive medication test 
    • 3-months new hire survey 
    • 3-month end of probation evaluation and feedback
    • 6- months’ recognition and celebration of a milestone
    • 12-month employee survey (job satisfaction/retention focus)
    • Annual evaluation and survey

References

Turn over review

• Al Zamel, L. G., Lim Abdullah, K., Chan, C. M., & Piaw, C. Y. (2020). Factors Influencing Nurses’ Intention to Leave and Intention to Stay: An Integrative Review. Home Health Care Management & Practice, 32(4), 218–228. https://doi-org.ezproxymcp.flo.org/10.1177/1084822320931363
• Çamveren, H., Kocaman, G., & Vatan, F. (2022). The effects of a preceptorship program on newcomer nurses’ turnover intention, commitment and job satisfaction: Quasi-experimental study. Nurse Education in Practice, 63. https://doi-org.ezproxymcp.flo.org/10.1016/j.nepr.2022.103358
• Choi, S., Shin, H., Lee, M., & Han, K. (2023). Relationship between Experience of Client Violence and Turnover Intention among Workers in Long-Term Care Facilities for Older Adults: Focusing on Nurses, Social Workers, and Care Workers. Nursing Reports (Pavia, Italy), 13(1), 549–560. https://doi.org/10.3390/nursrep13010050
• Eriksson, E., Jordal, M., Hjelm, K., & Engström, M. (2023). Job satisfaction and wellbeing among migrant care workers in nursing homes: An integrative review. Nursing Open, 10(6), 3486. https://doi-org.ezproxymcp.flo.org/10.1002/nop2.1611
• Forde-Johnston, C., & Stoermer, F. (2022). Giving nurses a voice through “listening to staff” conversations to inform nurse retention and reduce turnover. British Journal of Nursing, 31(12), 632-638–638. https://doi-org.ezproxymcp.flo.org/10.12968/bjon.2022.31.12.632
• Gandhi, A., Yu, H., & Grabowski, D. C. (2021). High Nursing Staff Turnover In Nursing Homes Offers Important Quality Information. Health Affairs, 3.
• Goyal, R., & Kaur, G. (2023). Determining the Role of Employee Engagement in Nurse Retention along with the Mediation of Organizational Culture. Healthcare (Switzerland), 11(5). https://doi-org.ezproxymcp.flo.org/10.3390/healthcare11050760
• Henshall, C., Davey, Z., & Jackson, D. (2020). Nursing resilience interventions-A way forward in challenging healthcare territories. Journal of clinical nursing, 29(19-20), 3597–3599. https://doi.org/10.1111/jocn.15276
• Hörberg, A., Rudman, A., Gadolin, C., Skyvell Nilsson, M., & Gustavsson, P. (2023). Experienced Nurses’ Motivation, Intention to Leave, and Reasons for Turnover: A Qualitative Survey Study. Journal of Nursing Management, 2023. https://doi-org.ezproxymcp.flo.org/10.1155/2023/2780839
• Keith, A. C., Warshawsky, N., & Talbert, S. (2021). Factors That Influence Millennial Generation Nurses' Intention to Stay: An Integrated Literature Review. The Journal of Nursing Administration, 51(4), 220–226. https://doi.org/10.1097/NNA.0000000000001001
• Kennedy, K. A., & Mohr, D. C. (2023). Job Characteristics Associated With Intent to Quit Among Nursing Home Employees and Managers. The Gerontologist, 63(1), 108–119. https://doi.org/10.1093/geront/gnac134
• Kishida K. (2022). The Effects of Wages and Training on Intent to Switch or Leave Among Direct Care Workers. Innovation in aging, 6(4), igac035. https://doi.org/10.1093/geroni/igac035
• Krein, S. L., Turnwald, M., Anderson, B., & Maust, D. T. (2022). "Sometimes it's not about the money... it's the way you treat people...": A Qualitative Study of Nursing Home Staff Turnover. Journal of the American Medical Directors Association, 23(7), 1178–1184. https://doi.org/10.1016/j.jamda.2021.11.036
• Lee, E., & De Gagne, J. C. (2022). The impact of resilience on turnover among newly graduated nurses: A 1-year follow-up study. Journal of Nursing Management, 30(5), 1295-1302–1302. https://doi-org.ezproxymcp.flo.org/10.1111/jonm.13613

• Lee J. (2022). Nursing home nurses' turnover intention: A systematic review. Nursing open, 9(1), 22–29. https://doi.org/10.1002/nop2.1051
• 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 Association, 15(2), 102–107. https://doi.org/10.1016/j.jamda.2013.09.003
• Li, Y., & Jones, C. B. (2013). A literature review of nursing turnover costs. Journal of Nursing Management, 21(3), 405-418–418. https://doi-org.ezproxymcp.flo.org/10.1111/j.1365-2834.2012.01411.x
• Lim J. (2021). Characteristics of Elderly Care Work That Influence Care Workers' Turnover Intentions. Healthcare (Basel, Switzerland), 9(3), 259. https://doi.org/10.3390/healthcare9030259
• Liu, C. C., Liu, L. F., & Chuang, S. S. (2022). The Effect of Ageist Behaviors on Home Care Workers' Job Satisfaction and Retention in Long-Term Care. Journal of Applied Gerontology : the Official Journal of the Southern Gerontological Society, 41(2), 322–331. https://doi.org/10.1177/0733464820975598
• Min, D., Cho, E., Kim, G. S., Lee, K. H., Yoon, J. Y., Kim, H. J., & Choi, M. H. (2022). Factors associated with retention intention of Registered Nurses in Korean nursing homes. International nursing review, 69(4), 459–469. https://doi.org/10.1111/inr.12754
• Nelson, H. W., Yang, B. K., Carter, M. W., Monahan, E., & Engineer, C. (2021). Nursing Home Administrator's Job Satisfaction, Work Stressors, and Intent to Leave. Journal of Applied Gerontology : the official Journal of the Southern Gerontological Society, 40(1), 67–76. https://doi.org/10.1177/0733464819896572
• Nonehkaran, E. A., Mozaffari, N., Iranpour, S., & Soola, A. H. (2023). Identifying the predictors of turnover intention based on nurse managers' toxic leadership behaviors among nurses in Iran: a cross-sectional correlational study. BMC Health Services Research, 23(1), 1201. https://doi.org/10.1186/s12913-023-10046-0
• Peerman C. (2021). The Relationship Between Leadership Styles, Job Satisfaction, and Tenure Among Nursing Home Administrators. Innovation in Aging, 5(Suppl 1), 372–373. https://doi.org/10.1093/geroni/igab046.1445
• Pförtner, T. K., Pfaff, H., & Hower, K. I. (2021). Will the demands by the covid-19 pandemic increase the intent to quit the profession of long-term care managers? A repeated cross-sectional study in Germany. Journal of Public Health, 43(3), e431–e434. https://doi.org/10.1093/pubmed/fdab081
• Reinhardt, A. C., León, T. G., & Amatya, A. (2020). Why nurses stay: Analysis of the registered nurse workforce and the relationship to work environments. Applied nursing research : ANR, 55, 151316. https://doi.org/10.1016/j.apnr.2020.151316
• Sharma, H., & Xu, L. (2022). Association Between Wages and Nursing Staff Turnover in Iowa Nursing Homes. Innovation in aging, 6(4), igac004. https://doi.org/10.1093/geroni/igac004
• Sun, C., Xing, Y., Wen, Y., Wan, X., Ding, Y., Cui, Y., Xu, W., Wang, X., Xia, H., Zhang, Q., & Yuan, M. (2023). Association between career adaptability and turnover intention among nursing assistants: the mediating role of psychological capital. BMC nursing, 22(1), 29. https://doi.org/10.1186/s12912-023-01187-y
• Van Aerschot, L., Mathew Puthenparambil, J., Kröger, T., & Olakivi, A. (2022). Psychophysical burden and lack of support: Reasons for care workers’ intentions to leave their work in the Nordic countries. International Journal of Social Welfare, 31(3), 333-346–346. https://doi-org.ezproxymcp.flo.org/10.1111/ijsw.12520
• Wang, J., Liu, S., Qu, X., He, X., Zhang, L., Guo, K., & Zhu, X. (2023). Nurses' Colleague Solidarity and Job Performance: Mediating Effect of Positive Emotion and Turnover Intention. Safety and health at work, 14(3), 309–316. https://doi.org/10.1016/j.shaw.2023.06.001
• Wei Hsu, & Fang-Chu Yang. (2022). Factors Associated with Home Health Aides’ Turnover Intention and Organizational Citizenship Behavior in Long-Term Care Services. Healthcare, 10(1743), 1743. https://doi-org.ezproxymcp.flo.org/10.3390/healthcare10091743
• Yan, E., Wan, D., To, L., Ng, H. K. L., Lai, D. W. L., Cheng, S. T., Kwok, T., Leung, E. M. F., Lou, V. W. Q., Fong, D., Chaudhury, H., Pillemer, K., & Lachs, M. (2023). Staff Turnover Intention at Long-Term Care Facilities: Implications of Resident Aggression, Burnout, and Fatigue. Journal of the American Medical Directors Association, S1525-8610(23)00879-4. Advance online publication. https://doi.org/10.1016/j.jamda.2023.10.008

References for Structured Program development 

• Akosa Antwi, Y., & Bowblis, J. R. (2018). The impact of nurse turnover on quality of care and mortality in nursing homes: Evidence from the great recession. American Journal of Health Economics, 4(2), 131-163–163. https://doi-org.ezproxymcp.flo.org/10.1162/ajhe_a_00096
• Cantrell, F. L., McKenzie, K., & Hessler, K. (2022). Task-Layered Clinical Orientation for New Graduate Registered Nurses. Journal for nurses in professional development, 38(2), E13–E18. https://doi.org/10.1097/NND.0000000000000841
• Cline, D., La Frentz, K., Fellman, B., Summers, B., & Brassil, K. (2017). Longitudinal Outcomes of an Institutionally Developed Nurse Residency Program. The Journal of Nursing Administration, 47(7-8), 384–390. https://doi.org/10.1097/NNA.0000000000000500
• Donoghue, C. (2010). Nursing home staff turnover and retention: An analysis of national level data. Journal of Applied Gerontology, 29(1), 89–106. doi:10.1177/0733464809334899
• Garcia, M. G., Watt, J. L., Falder-Saeed, K., Lewis, B., & Patton, L. (2017). Orienting and Onboarding Clinical Nurse Specialists: A Process Improvement Project. Clinical Nurse Specialist CNS, 31(3), 163–168. https://doi.org/10.1097/NUR.0000000000000294
• Griffeth, R. W., Hom, P. W., & Gaertner, S. (2011). A meta-analysis of antecedents and correlates of employee turnover: Update, moderator tests, and research implications for the next millennium. Journal of Management, 26(3), 463–488. https://doi.org/10.1016/S0149-2063(00)00043 –X
• Keith, A. C., Warshawsky, N., & Talbert, S. (2021). Factors That Influence Millennial Generation Nurses' Intention to Stay: An Integrated Literature Review. The Journal of nursing administration, 51(4), 220–226. https://doi.org/10.1097/NNA.0000000000001001
• Langley, T. M., Dority, J., Fraser, J. F., & Hatton, K. W. (2018). A Comprehensive Onboarding and Orientation Plan for Neurocritical Care Advanced Practice Providers. The Journal of Neuroscience Nursing: Journal of the American Association of Neuroscience Nurses, 50(3), 157–160. https://doi.org/10.1097/JNN.0000000000000359
• 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 Association, 15(2), 102–107. doi:10.1016/j.jamda.2013.09.003
• Loomer, L., Grabowski, D. C., Yu, H., & Gandhi, A. (2021). Association between nursing home staff turnover and infection control citations (SSRN Scholarly Paper ID 3766377). Social Science Research Network. https://papers.ssrn.com/abstract=3766377
• Montgomery, T., Harshman, J., Kennedy, S., Richards, K., & Shaw, M. (2020). Increasing Confidence Through the Development of a Transition-to-Practice Orientation Program for the Experienced Nurse. Journal for nurses in professional development, 36(6), E11–E17. https://doi.org/10.1097/NND.0000000000000661
• Reinhardt, A. C., León, T. G., & Amatya, A. (2020). Why nurses stay: Analysis of the registered nurse workforce and the relationship to work environments. Applied nursing research : ANR, 55, 151316. https://doi.org/10.1016/j.apnr.2020.151316
• Shin, J. H., Choi, G. Y., & Lee, J. (2020). Impact of nurse staffing, skill mix and stability on resident health outcomes in Korean nursing homes. Journal of Korean Gerontological Nursing, 22(4), 291–303. https://doi.org/10.17079/ jkgn.2020.22.4.291
• Shaikh, N. M., Kersten, P., Siegert, R. J., & Theadom, A. (2019). Developing a comprehensive framework of community integration for people with acquired brain injury: a conceptual analysis. Disability & Rehabilitation, 41(14), 1615–1631. https://doi-org.ezproxymcp.flo.org/10.1080/09638288.2018.1443163
• Thomas, K. S., Mor, V., Tyler, D. A., & Hyer, K. (2013). The relationships among licensed nurse turnover, retention, and rehospitalization of nursing home residents. The Gerontologist, 53(2), 211–221. https://doi.org/10.1093/geront/gns082
• Trinkoff, A. M., Han, K., Storr, C. L., Lerner, N., Johantgen, M., & Gartrell, K. (2013). Turnover, staffing, skill mix, and resident outcomes in a national sample of US nursing homes. The Journal of Nursing Administration, 43(12), 630–636. https://doi.org/10.1097/NNA.0000000000000004