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High Turnover Rate in Long-Term Care in Nursing

Paper Type: Free Essay Subject: Nursing
Wordcount: 2971 words Published: 30th Nov 2017

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  • Lisa Krier



There is a serious problem in this nation, and it is only getting worse. By the year 2030, the number of elderly in the United States, 85 years or older, is expected to reach 8.9 million (Barondess, 2007). According to the Center for Disease Control and Prevention’s website, two-thirds of people reaching the age of 65 will require the services of a long term care facility at least once during their lifetime (Harris-Kojetin, Sengupta, Park-Lee, Valverde, 2013). As the population continues to age, the population of those over the age of 65 is projected to soar to 88.5 million by the year 2050, and the oldest of the old, those 85 years and older, is estimated to reach 17.9 million and account for 4.5% of the U.S. population (Harris-Kojetin, Sengupta, Park-Lee, Valverde, 2013). The 85 and older population often have the highest disability rate and their need for long term care placement is the greatest (Harris-Kojetin, Sengupta, Park-Lee, Valverde, 2013). Unfortunately, the number of women who are 20 to 50 years old, the population most likely to provide the work force of direct care staff, is only expected to increase less than 10% during this same time (Barondess, 2007). In the United States, the shortage of direct-care staff is a serious problem that is worsening (Barondess, 2007). Recruitment and retention of direct- care staff is extremely challenging and is exacerbated by the growing division between the number of those needing care the number of those providing the care (Barondess, 2007).


Long term care facilities experience very high turnover rates among direct-care staff (Barondess, 2007). This problem is costly, threatens the quality of care provided to patients, increases workloads, and can lower morale among the remaining direct-care staff, with all of this contributing to continual and increased turnover (Barondess, 2007). According to the Institute of Medicine’s website, among direct-care staff there was a 71% turnover rate nationwide in 2008 and they were more likely to not have health insurance and to use food stamps (IOM, 2008). The high turnover rate of direct-care staff costs employers on average $4.1 billion annually (IOM, 2008).

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Direct-care staff contributes greatly to the physical and mental health of long term care patients (Stone & Wiener, 2001). Patients depend on staff for assistance with activities of daily living and direct-care staff is the ones providing this care (Stone & Wiener, 2001). According to the CDC, in 2012, direct-care staff spent on average 2.46 hours per day per patient, while RNs spent 0.52 hours per day per patient, and LPNs spend 0.85 hours per day per patient (Harris-Kojetin, Sengupta, Park-Lee, & Valverde, 2013). As the direct-care staff spends much time caring for the patient, real attachments between the care givers and patients can occur (Eaton, 2000). Direct-care staff potentially can help to improve the patient’s health and psychosocial functioning by providing positive interactions (Eaton, 2000). In this regard, high turnover rates in the long term care setting can affect patient care and patients may suffer both physically and emotionally as a result (Hayes et al., 2006). Staff turnover in the long term care industry increases the cost for caring for those patients and affects the quality of care provided (Rosen, Stiehl, Mittal, & Leana, 2011). In order to increase the retention of nursing assistants, administrators need to address the problem of low job satisfaction among these employees (Rosen, Stiehl, Mittal, & Leana, 2011). The following is a plan of action developed to address the problem of low job satisfaction and the high turnover rate of direct-care staff.

Core Competency

The core competency that will be addressed is managing patient-centered care (IOM, 2003). In 2003, the Institute of Medicine identified patient centered-care as: “identify, respect, and care about patient’s differences, values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate patients; share decision-making and management; and continuously advocate disease prevention, wellness, and promotion of health lifestyles, including a focus on population health” (IOM, 2003). In order for patient-centered care to be effective the staff must collaborate and coordinate care (Finkelman, 2012).

Knowledge, Skills, and Attributes

The KSA (Knowledge, Skills, and Attributes) that will be utilized for the Leadership Development Goal is team building conversations. High staffing turnover rates threaten the quality of care provided to patients and increases the financial burden of caring for those patients in long term care (Rosen, Mittal, & Leana, 2011). When direct-care staff has been asked what promotes the best care, the staff rated communication highest (Scott-Cawiezell et al., 2004), and also rated communication as the greatest weakness in the organization (Kostiwa & Meeks, 2009). Direct-care staff believes that they have a greater influence on quality of life for the patient than any other staff (Kane et al., 2006), and that high turnover rates undermine their relationships with patients (Bowers, Esmond, & Jacobson, 2000). Direct-care staff believes that the quality of care for patients is reflected in the quality of care for staff by the leadership (Burke, Summers, & Thompson, 2001). Given how direct-care staff feel about their ability to affect patient care and their need to feel supported by the leadership, sitting down with them and having conversations about how best to build the team is essential (Kostiwa & Meeks, 2009).

Leadership SMART Goal

I will examine the high turnover rate of direct-care staff in this long term care facility and meetings will take place with the direct-care staff and the management to begin building a strong team by engaging the direct-care staff in conversations regarding job satisfaction, reviewing peer-reviewed articles and credible websites, and to obtain information regarding job satisfaction from the direct-care staff through the use of employee surveys administered during the first meeting.

SMART Goal Format

Specifically, all direct-care staff, consisting of Certified Nursing Assistants and Medication Assistants, will sit down with management on a monthly basis to have team building discussions. The goal is to retain the direct-care staff by improving job satisfaction through providing access to authority, information, and teamwork (Boudrias, Gaudreau, & Laschinger, 2004), and therefore allowing the direct-care staff to have involvement in decision-making (Kostiwa & Meeks, 2009). These meetings will be scheduled during the first week of every month in the facility’s classroom and will occur at different times during the week to accommodate the direct-care staff from all of the shifts.

The effects of these meetings, improvement in job satisfaction (Kostiwa & Meeks, 2009) and the retention of direct-care staff (Rosen, Stiehl, Mittal, & Leana, 2011) will be measured by selecting five direct-care staff members from each of the three shifts and having them participate in a series of surveys (Kostiwa & Meeks, 2009). The employees selected to participate in the surveys must have completed the probationary period of employment. The first survey that will be administered is a psychological empowerment survey which consists of four categories, meaning, impact, competence, and self-determination (Spreitzer, 1995). Each category contains three questions and when all of the responses from each category are combined, an overall empowerment score is obtained (Spreitzer, 1995). Each item is rated on a seven point scale and higher scores represent opinions of increased empowerment (Spreitzer, 1995). The second survey that will be administered to the direct-care staff is the Organizational Cultural Inventory (Cooke & Rousseau, 1988). This inventory assesses what the direct-care staff believes to be the behavioral expectations of them in the facility (Cooke & Rousseau, 1988). The direct-care staff’s beliefs of service quality, commitment, role clarity, and role conflict are assessed on a scale from 1-5, or “not at all” to a “very great extent” (Cooke & Rousseau, 1988). High scores are indicative of stronger validation of the construct (Cooke & Rousseau, 1988). The third survey that the direct-care staff will be asked to complete is a nursing assistant job satisfaction survey (Ejaz, Noelker, Menne, & Bagakas, 2008), which includes 18 items that measure the employee’s satisfaction with recognition and communication time, the time allotted to complete tasks, resources available to staff, teamwork, and leadership practices (Ejaz, Noelker, Menne, & Bagakas, 2008). High levels of job satisfaction are related to high scores on the survey (Ejaz, Noelker, Menne, & Bagakas, 2008).

This goal is attainable as consistent meetings will take place on a monthly basis with direct-care staff and those in management. The direct-care staff will have the ability to have direct input and will have access to peer-reviewed research articles and evidence-based research provided by the management of the facility. During the first meeting, the credible websites of the Center for Disease Control (CDC, 2014) and the Institute of Medicine (IOM, 2008) will be reviewed for vital information regarding staffing issues in long term care. During the second meeting, which will take place during the first week of the second month, the research article The Relation Between Psychological Empowerment, Service Quality, and Job Satisfaction Among Certified Nursing Assistants, published in the Clinical Gerontologist (Kostiwa & Meeks, 2009) will be reviewed in correlation with the results of the surveys taken the previous month. The results of the surveys will be reviewed with the direct-care staff and an initial plan of action will be drawn. The articles Some Potential Solutions to High Direct-Care Staff Turnover Rates published in the Annuals of Long-Term Care (Barondess, 2008) and Stayers, Leavers, and Switchers Among Certified Nursing Assistants in Nursing Home: A Longitudinal Investigation of Turnover Intent, Staff Retention, and Turnover published in The Gerontologist (Rosen, Stiehl, Mittal, & Leana, 2011) will be discussed and made available for the staff to review at the third meeting, taking place during the first week of the third month. After the plan of action is created, it will be discussed at each monthly meeting to determine if the plan is succeeding in the goals set forth as well as any revisions that may be necessary.

This goal is realistic as perceptions of empowerment and service quality have been shown to be strongly and positively related to job satisfaction (Kostiwa & Meeks, 2009). Communication with management also affects job satisfaction (Scott-Cawiezell et al., 2004) as direct-care staff has consistently rated communication as the greatest weakness of their facility (Kostiwa & Meeks, 2009). Suggestions made by the direct-care staff will be reviewed with management and changes will then be implemented with input and discussion from the staff as well as management.

The time frame related to this goal will consist of monthly meetings with the direct-care staff and management both present. These meetings will take place during the first week of each month, with varying times to accommodate staff from all shifts. The surveys will be administered during the meeting in the first month, and then at six month intervals to measure whether or not job satisfaction rates are increasing. The program will be evaluated at the end of the first year to determine if the job satisfaction has increased and the turnover rate has decreased. Any changes to the program will be made at the end of the first year.


As the baby boomers retire and the population is expected to become much older, with 2/3rds of individuals over the age of 65 needing long term care services at least once in their lives, it is imperative that there is a sufficient workforce to care for these individuals (Harris-Kojetin, Sengupta, Park-Lee, & Valerde, 2013). As the population of women aging 20 to 50 years of age, the population most likely to provide the work force of direct-care staff, is only expected to increase less than 10% over the next 20 years, it is imperative to see job satisfaction rates improve and the turnover rates decline in this workforce (Barondess, 2007). With a comprehensive plan that includes involving the direct-care staff in the decision making process, having management and the direct-care staff participate in team building conversations on a monthly basis, and utilizing credible websites and peer-reviewed journal articles to obtain valuable information, this is one problem that can have a successful resolution.


Barondess, L.H. (2007). Some potential solutions to high direct-care staff turnover rates. Annuals of Long-Term Care, 15(10). Retrieved from http://www.annalsoflongtermcare.com/article/7860

Boudrias, J. S., Gaudreau, P., & Laschinger, H. K. S. (2004). Testing the structure of psychological empowerment: Does gender make a difference? Educational and Psychological Measurement, 64(5), 861-877.

Bowers, B. J., Esmond, S., & Jacobson, N. (2000). The relationship between staffing and quality in long-term care facilities: Exploring the views of nurse aides. Journal of Nursing Care Quality, 14(4), 55-65, 73-55.

Burke, G., III, Summers, J., & Thompson, T. (2001). Quality in long-term care: What we can learn from certified nursing assistants. Annuals of Long-Term Care, 9(2), 29-35.

Centers for Disease Control and Prevention (2014). Fast stats: Nursing home care. Retrieved from http://www.cdc.gov/nchs/faststats/nursing-home-care.html

Cooke, R. A., & Rousseau, D. M. (1988). Behavioral norms and expectations: A quantitative approach to the assessment of organizational culture. Group & Organization Studies, 13(3), 245-273.

Eaton, S. C. (2000). Beyond ‘unloving care’: Linking human resource management and patient care quality in nursing homes. International Journal of Human Resource Management, 11(3), 591-616.

Ejaz, F. K., Noelker, L. S., Menne, H. L., & Bagakas, J. G. (2008). The impact of stress and support on direct-care workers’ job satisfaction. The Gerontologist, 48(Special Issue 1), 60-70.

Finkelman, A. (2012). Leadership and management for nurses: Core competencies for quality care (2nd ed.). Boston, MA: Pearson.

Harris-Kojetson, L., Sengupta, M., Park-Lee, E., Valverde, R. (2013). Long-term care services in the United States: 2013 overview. Hyattsville, MD: National Center for Health Statistics.

Hayes, L.J., O’Brien-Pallas, L., Duffield, C., Shamian J., Buchan, J., Hughes, F., et al. (2006). Nurse turnover: A literature review. International Journal of Nursing Studies, 32(2), 237-263.

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Kostiwa, I.M., & Meeks, S., (2009). The relation between psychological empowerment, service quality, and job satisfaction among certified nursing assistants. Clinical Gerontologist, 32, 276-292. doi:10.1080/07317110902895309

Rosen, J., Mittal, E.M., Leana, C.R. (2011). Stayers, leavers, and switchers among certified nursing assistants in nursing home: A longitudinal investigation of turnover intent, staff retention, and turnover. The Gerontologist, 51(5), 597-609.

Scott-Cawiezell, J., Schenkman, M., Moore, L. Vojir, C., Connoly, R. P., Pratt, M., et al. (2004). Exploring nursing home staff’s perceptions of communication and leadership to facilitate quality improvement. Journal of Nursing Care Quality, 19(3), 242-252.

Spreitzer, G. M. (1995). Psychological empowerment in the workplace: Dimensions, measurement and validation. Academy of Management Journal, 38(5), 1442.

Stone, R. I., & Wiener, J. M. (2001). Who will care for us? Addressing the long-term care workforce crisis. Washington, DC: The Urban Institute.


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