- Email: [email protected]
Are Nursing Home Survey Deficiencies Higher in Facilities With Greater Staff Turnover
JAMDA 15 (2014) 102e107
JAMDA journal homepage: www.jamda.com
Original Study
Are Nursing Home Survey Deficiencies Higher in Facilities With Greater Staff Turnover Nancy B. Lerner RN, DNP a, *, Meg Johantgen RN, PhD a, Alison M. Trinkoff RN, ScD a, Carla L. Storr ScD a, Kihye Han RN, PhD b a b
University of Maryland School of Nursing, Baltimore, MD Chung-Ang University Red Cross College of Nursing, Seoul, South Korea
a b s t r a c t Keywords: Nursing home deficiency staffing turnover nursing assistant resident outcome
Objectives: To examine CNA and licensed nurse (RNþLPN/LVN) turnover in relation to numbers of deficiencies in nursing homes. Design: A secondary data analysis of information from the National Nursing Home Survey (NNHS) and contemporaneous data from the Online Survey, Certification and Reporting (OSCAR) database. Data were linked by facility as the unit of analysis to determine the relationship of CNA and licensed nurse turnover on nursing home deficiencies. Setting: The 2004 NNHS used a multistage sampling strategy to generate a final sample of 1174 nursing homes, which represent 16,100 NHs in the United States. Participants: This study focused on the 1151 NNHS facilities with complete deficiency data. Measurements: Turnover was defined as the total CNAs/licensed nurse full-time equivalents (FTEs) who left during the preceding 3 months (full- and part-time) divided by the total FTE. NHs with high turnover were defined as those with rates above the 75th percentile (25.3% for CNA turnover and 17.9% for licensed nurse turnover) versus all other facilities. This study used selected OSCAR deficiencies from the Quality of Care, Quality of Life, and Resident Behavior categories, which are considered to be more closely related to nursing care. We defined NHs with high deficiencies as those with numbers of deficiencies above the 75th percentile versus all others. Using SUDAAN PROC RLOGIST, we included NNHS sampling design effects and examined associations of CNA/licensed nurse turnover with NH deficiencies, adjusting for staffing, skill mix, bed size, and ownership in binomial logistic regression models. Results: High CNA turnover was associated with high numbers of Quality of Care (OR 1.53, 95% CI 1.10 e2.13), Resident Behavior (OR 1.42, 95% CI 1.03e1.97) and total selected deficiencies (OR 1.54, 95% CI 1.12 e2.12). Licensed nurse turnover was significantly related to Quality of Care deficiencies (OR 2.06, 95% CI 1.50e2.82) and total selected deficiencies (OR 1.71, 95% CI 1.25e2.33). When both CNA turnover and licensed nurse turnover were included in the same model, high licensed nurse turnover was significantly associated with Quality of Care and total deficiencies, whereas CNA turnover was not associated with that category of deficiencies. Conclusion: Turnover in nursing homes for both licensed nurses and CNAs is associated with quality problems as measured by deficiencies. Ó 2014 - American Medical Directors Association, Inc. All rights reserved.
Recruitment and retention of nursing home staff to provide for the increasing number of elderly requiring care in the future is a continuing concern for nursing home administrators and nursing directors. Without a change in workforce trends, high-quality care for older Americans cannot be guaranteed.1 Turnover of nursing staff is of This study was funded by the National Council of State Boards of Nursing, grant no. R40009. The authors declare no conflicts of interest. * Address correspondence to Nancy B. Lerner, RN, DNP, 655 West Lombard Street, Rm 325A, Baltimore, MD 21201. E-mail address: [email protected] (N.B. Lerner).
concern for nursing home quality due to high annual turnover rates estimated at 46.7% (registered nurses [RNs]), 41.8% (licensed practical nurses or licensed vocational nurses [LPN/LVN]), and 46.6% (certified nursing assistants [CNAs]).2 Although turnover rates decreased somewhat for LPN/LVNs and CNAs since 2007, perhaps due to the economic recession, RN turnover has increased.3 High turnover has been associated with increased adverse resident outcomes, as reflected in higher quality indicator rates and increased rehospitalization rates.4,5 Factors other than turnover also may influence quality of care within nursing homes. Organizational factors, such as staffing and skill mix, have been related to care
1525-8610/$ - see front matter Ó 2014 - American Medical Directors Association, Inc. All rights reserved. http://dx.doi.org/10.1016/j.jamda.2013.09.003
N.B. Lerner et al. / JAMDA 15 (2014) 102e107
outcomes. Decreased rates of pressure ulcers with increased RN staffing have been well documented.6e8 Decreased restraint usage and lower rates of infection and weight loss associated with increased RN staffing also have been reported.8,9 Increased RN staffing, combined with less turnover of RNs and CNAs and limited agency use, has been associated with lower restraint usage, lower catheter and pressure sore rates, and improved pain management, whereas LPN/ LVN turnover and staffing were not associated with better quality indicators.4 In addition, licensed nurse turnover has been associated with higher rehospitalization rates for nursing home residents. 5 Despite these individual associations between organizational factors and nursing home quality, a recent systematic review of the relationship between staffing and quality found that a relationship could not be determined conclusively.10 Deficiency citations provide another measure of quality for nursing homes. The Centers for Medicare and Medicaid Services (CMS) mandates reviews of all nursing homes by teams of state-based interdisciplinary surveyors approximately once a year and follow-up of complaints received by the state survey agencies. The nursing homes are evaluated on standards developed by CMS and are given deficiencies when the facility’s performance is not in substantial compliance with the standards. Staffing and skill mix have been associated with decreased nursing home deficiencies.11,12 However, the relationship of turnover to deficiencies has not been reported since Munroe13 identified a relationship between licensed staff turnover and deficiencies more than 20 years ago. We hypothesized that in nursing homes where turnover is higher, more nursing-related deficiencies will occur. In addition, we hypothesized that after adjustment for staffing and skill mix, turnover will maintain an independent relationship to nursing-related deficiencies.
103
collected by interdisciplinary surveyors who visit each nursing home every 9 to 15 months and review care based on 180 federal regulatory standards in 15 categories. This study used OSCAR deficiency data from 2004 to coincide with the 2004 NNHS data. Sample This study focused on the 1151 facilities with complete deficiency data (23 NHs were excluded). In addition, 143 facilities had missing CNA turnover data and 139 had missing licensed nurse turnover data, and were therefore excluded from the statistical models. NH characteristics of those with and without turnover information were similar. Deficiency Outcomes This study used all deficiencies from the Quality of Care (QOC), Quality of Life (QOL), and Resident Behavior (RB) categories, which are considered to be more closely related to nursing care than categories such as administration, pharmacy, and environment.6,12 A total of 50 deficiencies were contained in these categories: 25 QOC deficiencies (eg, activities of daily living, continence, pressure ulcers and range of motion), 19 QOL deficiencies (focused on housekeeping, social service, and activities), and 6 RB deficiencies (eg, restraint use, freedom from abuse, and staff treatment of residents). A summed score of the number of deficiencies for each category (eg, QOC, QOL, RB) and an overall total were calculated. These totals were not normally distributed, so deficiency scores were dichotomized into “high” (facilities with deficiencies in that category above the 75th percentile) versus “low” (facilities with deficiencies at or below the 75th percentile in that category).
Methods
Turnover
Design and Data Sources
Two types of turnover were calculated for this study: CNA and licensed nurse turnover based on the NNHS 3-month turnover data. CNA turnover was defined as CNA FTEs for those who left during the previous 3 months (combining full- and part-time workers) divided by the total CNA FTEs.15e17 Part-time workers were defined as 0.50 FTE. Similar formulas were used to calculate licensed nurse turnover, which combined RN and licensed practical nurse FTEs (RN þ LPN/LVN). Nursing homes were categorized as having high turnover when the turnover rate exceeded the 75th percentile. Turnover included both voluntary (resignation) and involuntary (termination) separations.
The overall design was a secondary data analysis using contemporaneous information from the National Nursing Home Survey (NNHS) and the Online Survey, Certification, and Reporting (OSCAR) database. Data were linked by facility as the unit of analysis to determine the relationship of CNA and licensed nurse turnover on deficiencies thought to be sensitive to care provided by licensed and unlicensed nursing staff. The study protocol was reviewed and approved by the University of Maryland Baltimore Institutional Review Board. The 2004 National Nursing Home Survey (NNHS) is the seventh and final survey of a series about nursing homes conducted since 1973 by the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC/NCHS). The NNHS collects data on staffing levels, types, and full-time equivalents (FTEs) of practitioners, turnover, and overtime solicited from computer-assisted face-to-face interviews with nursing home administrators and staff. Additional data include type of services offered and general nursing home characteristics, such as number of beds, ownership, and resident characteristics. To select the sample of nursing homes for the 2004 NNHS, NCHS used a multistage sampling strategy, stratifying on the number of beds and metropolitan area. They then arrayed nursing homes by certification status, hospital relationship (hospital- and nonehospital-based), ownership, geographic region, state, county, and zip code.14 The final sample of 1174 homes that participated can be weighted to be representative of US nursing homes. Because our study linked NNHS turnover data to outcomes data by facility, the NNHS restricted use dataset was used. OSCAR is a CMS-maintained data network in cooperation with state long term care surveying agencies. OSCAR deficiency data were
Control Variables Staffing and skill mix were included in the analysis as control variables and were obtained from the NNHS database for CNAs, licensed nurses (RN þ LPN/LVN), and total staffing. Total staffing was equal to the RN, LPN/LVN, CNA, and aides’ total hours per resident day (HPRD)17 and was dichotomized as greater than 5.0 HPRD or not. Skill mix was defined as the licensed nurse (RN þ LPN/LVN) FTEs divided by all total staffing FTEs (RN, LPN/LVN, CNA, aides). In addition, control variables included nursing home characteristics, such as facility size (3e49, 50e99, 100e199 versus 200 beds) and ownership (for-profit versus all others) obtained from the NNHS. Criteria for control variables were based on prior definitions found in the literature.9,17,18 Data Analysis Analyses were conducted on the merged data after obtaining approval from the NCHS Research Data Center (RDC). Sampling
104
N.B. Lerner et al. / JAMDA 15 (2014) 102e107
Table 1 Study Nursing Home Characteristics, Weighted, 2004 National Nursing Home Survey (NNHS)
Unweighted no. of nursing homes Weighted no. of nursing homes represented Three-month turnover, % CNA, mean (95% CI), range Licensed nurse, mean (95% CI), range Skill mix (licensed nurse proportion, %), mean (95% CI), range Nurse staffing, n (%) 5 hours per resident day <5 hours per resident day No. of beds, n (%) 3e49 50e99 100e199 200 Ownership, n (%) For-profit All others Affiliation, n (%) Chain Independent Occupancy rate, n (%) <70% 70%e79% 80%e89% 90%e94% 95%
NNHS Nursing Homes
NHs With Deficiency Data
1174 16362
1151 16040
16.2 (15.1e17.2), 0.0e182.8 11.6 (10.6e12.5), 0.0e200.0 33.9 (33.4e34.5), 9.8e100.0
16.2 (15.1e17.2), 0.0e182.8 11.7 (10.7e12.6), 0.0e200.0 33.9 (33.4e34.5), 9.8e100.0
1728 (12.0) 12708 (88.0) 2295 6168 6876 1023
1632 (11.5) 12509 (88.5)
(14.0) (37.7) (42.0) (6.3)
2173 6041 6818 1008
(13.6) (37.7) (42.5) (6.3)
10079 (61.6) 6283 (38.4)
9990 (62.3) 6050 (37.7)
8863 (54.2) 7499 (45.8)
8770 (54.7) 7270 (45.3)
2055 1888 3700 3065 5654
1906 1861 3654 3029 5590
(12.6) (11.5) (22.6) (18.7) (34.6)
(11.9) (11.6) (22.8) (18.9) (34.9)
CI, confidence interval; CNA, certified nursing assistant.
weights were applied using SUDAAN (Research Triangle Institute International, Research Triangle Park, NC) to correct for design effects of the complex sampling strategy used in the NNHS. Although these data underwent extensive cleaning before release, additional data quality and completeness checks were conducted, and frequencies were compared with benchmarks from the nonconfidential (public use) NNHS data. Associations were explored and model assumptions tested using SAS-callable SUDAAN (version 10.0.1) PROC RLOGIST. Each category of deficiencies was modeled separately and again as a total of all included deficiencies. Three sets of models were generated, one for CNA turnover, the second for licensed nurse turnover, and the third set contained both CNA and licensed nurse turnover in relation to deficiencies. After first noting crude associations (bivariate), models were then adjusted for staffing, skill mix, number of beds, and ownership. Similar results were obtained when turnover
was modeled as a continuous and categorical variable. Based on better model fit, we present the findings from the categorical models, comparing those with high deficiencies (above 75th percentile to all others). Results As shown in Table 1, estimated CNA turnover for a 3-month period was 16.2% (95% confidence interval [CI] 15.1e17.2; range, 0.0e182.8) and licensed nurse turnover was 11.7% (95% CI 10.7e12.6; range, 0.0e200.0). Most NHs had total HPRD below 5 (88.5%), were for-profit (62.3%); 54.7 % were chain affiliated. Most NHs had between 50 and 199 beds (80.2%) with only 6.3% of facilities having 200 or more beds. CNA turnover was related to nursing care deficiencies (Table 2), with high turnover increasing the odds of having high total
Table 2 Estimated Associations Between CNA Turnover and Nursing Care Deficiencies in a Representative Sample of US Nursing Homes (n ¼ 1151) Total Nursing Care Deficiencies*
Quality of Care Deficiencies*
Quality of Life Deficiencies*
Resident Behavior Deficiencies*
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
1.14e2.10
1.52
1.11e2.09
1.24
0.85e1.82
1.36
1.00e1.86
1.16e2.16 0.78e1.86 0.97e0.99
1.51 0.94 0.98
1.09e2.08 0.59e1.52 0.97e1.00
1.25 1.19 0.98
0.85e1.85 0.69e2.07 0.96e1.00
1.43 1.41 0.99
1.04e1.97 0.91e2.17 0.97e1.00
1.12e2.12 0.78e1.89 0.97e1.00 0.24e0.95 0.32e1.04 0.48e1.52 0.84e1.54
1.53 0.94 0.99 0.56 0.62 0.91 0.95
1.10e2.13 0.58e1.52 0.97e1.00 0.28e1.13 0.33e1.13 0.50e1.65 0.70e1.28
1.16 1.24 0.99 0.30 0.64 0.54 1.29
0.78e1.72 0.71e2.14 0.96e1.01 0.12e0.73 0.32e1.25 0.27e1.05 0.89e1.88
1.42 1.42 0.99 0.93 0.97 0.88 1.03
1.03e1.97 0.92e2.18 0.97e1.00 0.47e1.87 0.53e1.80 0.48e1.63 0.76e1.40
Model 1: crude association CNA turnover,y high vs low 1.54 Model 2: adjusted for staffing and skill mix y 1.58 CNA turnover, high vs low Nurse staffing, 5 HPRD vs <5 HPRD 1.20 Skill mix, licensed nurse proportion 0.98 Model 3: also adjusting for nursing home characteristics 1.54 CNA turnover,y high vs low Nurse staffing, 5 HPRD vs <5 HPRD 1.21 Skill mix, licensed nurse proportion 0.99 No. of beds, <50 vs 200 0.48 50e99 vs 200 0.58 100e199 vs 200 0.85 Ownership, for profit vs not 1.14
CI, confidence interval; CNA, certified nursing assistant; HPRD, hours per resident day; OR, odds ratio. *>75th percentile (vs 75th percentile) for number of deficiencies. y Turnover high (>75th percentile) and low (75th percentile).
N.B. Lerner et al. / JAMDA 15 (2014) 102e107
105
Table 3 Estimated Associations Between Licensed Nurse (RN þ LPN/LVN) Turnover and Nursing Care Deficiencies in a Representative Sample of US Nursing Homes (n ¼ 1151) Total Nursing Care Deficiencies*
Quality of Care Deficiencies*
Quality of Life Deficiencies*
Resident Behavior Deficiencies*
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
1.29e2.36
2.10
1.55e2.85
1.48
1.02e2.14
1.23
0.90e1.68
1.27e2.35 0.79e1.90 0.97e1.00
2.04 1.02 0.98
1.49e2.78 0.63e1.65 0.97e0.99
1.46 1.25 0.98
0.99e2.13 0.72e2.16 0.96e0.99
1.25 1.37 0.99
0.91e1.71 0.89e2.10 0.97e1.00
1.25e2.33 0.80e1.95 0.97e1.01 0.23e0.90 0.32e1.02 0.46e1.44 0.86e1.57
2.06 1.02 0.99 0.53 0.59 0.86 0.94
1.50e2.82 0.62e1.65 0.97e1.00 0.26e1.07 0.32e1.08 0.47e1.55 0.69e1.28
1.44 1.32 0.99 0.29 0.62 0.52 1.28
0.98e2.12 0.76e2.28 0.97e1.01 0.12e0.71 0.32e1.22 0.26e1.01 0.88e1.85
1.24 1.38 0.99 0.91 0.97 0.87 1.07
0.90e1.71 0.90e2.13 0.97e1.00 0.46e1.81 0.53e1.80 0.47e1.59 0.79e1.44
Model 1: crude association 1.75 Licensed nurse turnover,y high vs low Model 2: adjusted for staffing and skill mix 1.72 Licensed nurse turnover,y high vs low Nurse staffing, 5 HPRD vs <5 HPRD 1.22 Skill mix, licensed nurse proportion 0.98 Model 3: also adjusting for nursing home characteristics y 1.71 Licensed nurse turnover, high vs low Nurse staffing, 5 HPRD vs <5 HPRD 1.25 Skill mix, licensed nurse proportion 0.99 Number of beds, <50 vs 200 0.45 50e99 vs 200 0.57 100e199 vs 200 0.81 Ownership, for profit vs not 1.16
CI, confidence interval; HPRD, hours per resident day; LPN/LVN, licensed practical nurse or licensed vocational nurse; OR, odds ratio; RN, registered nurse. *>75th percentile (vs 75th percentile) for number of deficiencies. y Turnover high (>75th percentile) and low (75th percentile).
deficiencies by 54% (OR 1.54, 95% CI 1.14e2.10). By deficiency category, associations were strongest for QOC (OR 1.52, 95% CI 1.11e2.09) and RB (OR 1.36, 95% CI 1.00e1.86) deficiencies but did not reach significance for the QOL category. The significant relationships did not change when control variables were added. Lower skill mix was also significantly related to more total deficiencies (OR 0.98, 95% CI 0.97e0.99), but not when bed size and ownership were added to the model. Licensed nurse turnover was also significantly related to total deficiencies (OR 1.75, 95% CI 1.29e2.36) and QOC deficiencies (OR 2.10, 95% CI 1.55e2.85), even after control variables were added to the model (Table 3). Skill mix was significantly associated with QOC and QOL deficiencies (OR 0.98, 95% CI 0.97e0.99), but these relationships were no longer significant when number of beds and ownership were controlled (model 3). When CNA and licensed nurse turnover were included in the same model (Table 4), high licensed nurse turnover was significantly associated with QOC deficiencies (OR 1.92, 95% CI 1.38e2.69) and total deficiencies (OR 1.56, 95% CI 1.12e2.17), whereas CNA turnover was not associated with that category of deficiencies.
These findings were the same with and without the inclusion of control variables. Discussion High CNA turnover was related to higher numbers of QOC, RB, and total deficiencies in nursing homes, and these associations remained after adjustment. CNA turnover was not associated with QOL deficiencies. Although CNA turnover has been associated with poor quality indicators in nursing homes and poor end-of-life care,4,19,20 this is the first study to find CNA turnover was related to deficiencies. The QOC deficiencies include activities of daily living, continence, pressure ulcers, and range of motion, all of which involve tasks primarily performed by CNAs. The deficiencies dealing with resident behavior also depend on knowledgeable CNA care, as they deal with restraints, freedom from abuse, and staff treatment of residents. The lack of familiarity with residents and their requirements that can accompany CNA turnover would be expected to adversely affect care in these categories. Conversely, QOL deficiencies also involve work by other providers, such as housekeeping, social service, and activity
Table 4 Estimated Associations Between Nursing Staff Turnover and Nursing Care Deficiencies in a Representative Sample of US Nursing Homes (n ¼ 1151)
Model 1 CNA turnover,y high vs low Licensed nurse turnover,y high vs low Model 2 CNA turnover,y high vs low Licensed nurse turnover,y high vs low Nurse staffing, 5 HPRD vs <5 HPRD Skill mix, licensed nurse proportion Model 3 CNA turnover,y high vs low Licensed nurse turnover,y high vs low Nurse staffing, 5 HPRD vs <5 HPRD Skill mix, licensed nurse proportion Number of beds, <50 vs 200 50e99 vs 200 100e199 vs 200 Ownership, for profit vs not
Total Nursing Care Deficiencies*
Quality of Care Deficiencies*
Quality of Life Deficiencies*
Resident Behavior Deficiencies*
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
1.34 1.59
0.97e1.86 1.15e2.19
1.22 1.96
0.87e1.72 1.41e2.72
1.10 1.43
0.73e1.66 0.96e2.13
1.32 1.12
0.95e1.84 0.81e1.56
1.38 1.57 1.28 0.98
0.99e1.92 1.13e2.17 0.83e1.99 0.97e1.00
1.23 1.91 1.04 0.99
0.87e1.74 1.37e2.66 0.64e1.69 0.97e1.00
1.12 1.40 1.25 0.98
0.74e1.71 0.93e2.10 0.72e1.29 0.96e1.00
1.38 1.13 1.43 0.99
0.99e1.92 0.81e1.57 0.93e2.21 0.97e1.00
1.34 1.56 1.29 0.99 0.46 0.56 0.82 1.12
0.96e1.89 1.12e2.17 0.82e2.03 0.97e1.01 0.23e0.91 0.31e1.01 0.46e1.46 0.83e1.52
1.25 1.92 1.03 0.99 0.53 0.59 0.86 0.92
0.88e1.78 1.38e2.69 0.63e1.69 0.97e1.01 0.26e1.07 0.32e1.08 0.48e1.55 0.68e1.25
1.03 1.42 1.31 0.99 0.29 0.62 0.52 1.28
0.68e1.57 0.94e2.14 0.75e2.28 0.97e1.01 0.12e0.71 0.32e1.22 0.26e1.02 0.88e1.86
1.37 1.13 1.44 0.99 0.93 0.97 0.87 1.03
0.98e1.92 0.81e1.58 0.93e2.22 0.97e1.00 0.46e1.86 0.52e1.79 0.47e1.61 0.76e1.39
CI, confidence interval; CNA, certified nursing assistant; HPRD, hours per resident day; OR, odds ratio. *>75th percentile (vs 75th percentile) for number of deficiencies. y Turnover high (>75th percentile) and low (75th percentile).
106
N.B. Lerner et al. / JAMDA 15 (2014) 102e107
staff in addition to CNAs, thus the lack of an association between CNA turnover and deficiencies in this category is not surprising. The influence of licensed nurse turnover on total and QOC deficiencies even after adjustment for staffing, skill mix, bed size and ownership, mirrors the 1990 results of Munroe,13 who identified an association between licensed staffing and quality in a model that he developed. Licensed nurse turnover has likewise been associated with decreased quality of care in nursing facilities, as demonstrated by CMS Quality Indicators.4,9,19 Licensed nurse turnover was also a factor in the quality of end-of-life care in nursing facilities21 and has been shown to be a factor in rehospitalization rates for nursing home patients.5 Although we hypothesized that turnover would increase the odds of deficiencies, we did not expect the strength of CNA turnover when licensed turnover was included in the model. For total and RB deficiencies, only CNA turnover remained significant when the other variables were all entered into the model. In nursing facilities, patient care is largely dependent on the CNA staff. 21,22 Consistent assignment of nursing assistants to the same patient has been associated with improved quality of care.23,24 Recently, consistent assignment also was associated with reduced turnover and with decreased deficiencies, so as a mechanism for reduced turnover and improved care quality it should be further examined.25 Other factors found to be associated with low turnover of CNA staff include organizational factors, such as staffing, wages, and involvement in care planning and positive work relationships.26,27 On the other hand, for QOC deficiencies, licensed nurse turnover was the more important factor. This is logical because many QOC deficiencies include domains for which licensed providers are responsible, such as medications, nasogastric tube care, nutrition, and hydration. They are noted as F-tags, that is, deficiencies that relate to CMS care standards, with the F-tag matching the number for the CMS care standard.28 In addition, F-tag 309, “Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care,”28 specifically relates to assessing, planning, and implementing care under the purview of licensed nursing staff. Limitations This study was limited by the use of cross-sectional data and that both the NNHS and OSCAR data were collected in 2004, the latest year for which the NNHS data are available. The exclusion of some facilities because of unavailable data also may have affected the findings. Therefore, despite a good participation rate and limited missing data in both surveys, caution must be taken in generalizing results to all facilities. The analysis of deficiencies was also limited through selection of deficiencies from 3 categories, although these were chosen based on previous research that identified the selected deficiencies as those most likely to be nursingsensitive. Our findings also may have been influenced by the use of deficiencies as a dependent variable, because reported deficiencies are dependent on the surveyors performing the actual survey and wide variation has been identified between different teams of surveyors and across states.29 Surveyor variation has also been found in stipulating which specific regulation a nursing home did not meet, although agreement existed in the number of deficiencies.30 Conclusion Turnover in nursing homes for both licensed nurses and CNAs is an ongoing problem that also impacts the quality of care for nursing
home residents. Continued research using deficiencies as a measure of quality, in addition to the quality indicators used by others, should be beneficial. In addition, easily accessible resources are needed for nursing home administrators and directors of nursing to help them address the relationship between turnover and quality and to assist with creating a more stable care environment. More study on interventions that lower nursing home turnover for all levels of staff is sorely needed, along with dissemination of interventions shown to reduce turnover. References 1. Institute of Medicine. Retooling for an aging America: Building the healthcare workforce. 2008. Available at: http://www.iom.edu/Reports/2008/Retooling-foran-Aging-America-Building-the-Health-Care-Workforce.aspx. Accessed May 15, 2013. 2. American Health Care Association. LTC stats: Nursing facility operational characteristics report. 2011. Available at: http://www.ahcancal.org/research_ data/oscar_data/Nursing%20Facility%20Operational%20Characteristics/Operational CharacteristicsReport_Dec2011.pdf. Accessed May 15, 2013. 3. American Health Care Association. Report of findings 2007 AHCA survey: Nursing staff vacancy and turnover in nursing facilities. 2008. Available at: http://www. ahcancal.org/research_data/staffing/Documents/Vacancy_Turnover_Survey2007. pdf. Accessed May 15, 2013. 4. Castle NG, Anderson RA. Caregiver staffing in nursing homes and their influence on quality of care: Using dynamic panel estimation methods. Med Care 2011;49:545e552. 5. Thomas KS, Mor V, Tyler DA, Hyer K. The relationships among licensed nurse turnover, retention, and rehospitalization of nursing home residents. Gerontologist 2013;53:211e221. 6. Bowblis JR. Staffing ratios and quality: An analysis of minimum direct care staffing requirements for nursing homes. Health Serv Res 2011;46:1495e1516. 7. Horn SD, Buerhaus P, Bergstrom N, Smout RJ. RN staffing time and outcomes of long-stay nursing home residents: Pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care. Am J Nurs 2005; 105:58e70. 8. Weech-Maldonado R, Meret-Hanke L, Neff MC, Mor V. Nurse staffing patterns and quality of care in nursing homes. Health Care Manage Rev 2004;29: 107e116. 9. Castle NG, Engberg J. Staff turnover and quality of care in nursing homes. Med Care 2005;43:616e626. 10. Spilsbury K, Hewitt C, Stirk L, Bowman C. The relationship between nurse staffing and quality of care in nursing homes: A systematic review. Int J Nurs Stud 2011;48:732e750. 11. Harrington C, Olney B, Carrillo H, Kang T. Nurse staffing and deficiencies in the largest for-profit nursing home chains and chains owned by private equity companies. Health Serv Res 2012;47:106e128. 12. Kim H, Kovner C, Harrington C, et al. A panel data analysis of the relationships of nursing home staffing levels and standards to regulatory deficiencies. J Gerontol B Psychol Sci Soc Sci 2009;64:269e278. 13. Munroe DJ. The influence of registered nurse staffing on the quality of nursing home care. Res Nurs Health 1990;13:263e270. 14. CDC/National Center for Health Statistics. The National Nursing Home Survey: 2004 overview. 2009. Available at: http://www.cdc.gov/nchs/data/series/sr_ 13/sr13_167.pdf. Accessed May 15, 2013. 15. Castle NG. Measuring staff turnover in nursing homes. Gerontologist 2006;46: 210e219. 16. Donoghue C. Nursing home staff turnover and retention: An analysis of national level data. J Appl Gerontol 2010;29:89e106. 17. Temple A, Dobbs D, Andel R. Exploring correlates of turnover among nursing assistants in the National Nursing Home Survey. Health Care Manage Rev 2009; 34:182e190. 18. Decker FH, Castle NG. Relationship of the job tenure of nursing home top management to the prevalence of pressure ulcers, pain, and physical restraint use. J Appl Gerontol 2010;30:539e561. 19. Castle NG, Engberg J, Men A. Nursing home staff turnover: Impact on nursing home compare quality measures. Gerontologist 2007;47:650e661. 20. Tilden VP, Thompson SA, Gajewski BJ, et al. Sampling challenges in nursing home research. J Am Med Dir Assoc 2013;14:25e28. 21. McConnell ES, Lekan D, Corazzini KN. Assuring the adequacy of staffing of longterm care, strengthening the caregiving workforce, and making long-term care a career destination of choice: from mission impossible to mission critical? N C Med J 2010;71:153e157. 22. Houser A, Fox-Grage W, Gibson MJ. Across the States 2009: Profiles of LongTerm Care and Independent Living. 8th ed. Washington, DC: AARP Public Policy Institute; 2009. 23. Scandrett KG, Anichini MA, Berdes C, et al. Patient safety in the nursing home: How nursing staff assess and communicate about change in condition. J Gerontol Nurs 2012;38:28e37. 24. Castle NG. Consistent assignment of nurse aides: Association with turnover and absenteeism. J Aging Soc Policy 2013;25:48e64.
N.B. Lerner et al. / JAMDA 15 (2014) 102e107 25. Castle NG. The influence of consistent assignment on nursing home deficiency citations. Gerontologist 2011;51:750e760. 26. Dill DM, Keefe JM, McGrath DS. The influence of intrinsic and extrinsic job values on turnover intention among continuing care assistants in Nova Scotia. Home Health Care Serv Q 2012;31:111e129. 27. Temple A, Dobbs D, Andel R. Exploring correlates of turnover among nursing assistants in the national nursing home survey. J Nurs Adm 2011;41:S34eS42. 28. CMS Manual System Department of Health & Human Services (DHHS) Pub. 10007 State Operations Provider Certification: F tag 309—Quality of Care- Advance
107
Copy. Available at: http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter12-48.pdf. Accessed October 1, 2013. 29. Office of the Inspector General. Nursing home deficiency trends and survey and certification process consistency. 2003. Available at: http://oig.hhs.gov/oei/ reports/oei-02-01-00600.pdf. Accessed May 15, 2013. 30. Lee RH, Gajewski BJ, Thompson S. Reliability of the nursing home survey process: A simultaneous survey approach. Gerontologist 2006;46: 772e779.
JAMDA journal homepage: www.jamda.com
Original Study
Are Nursing Home Survey Deficiencies Higher in Facilities With Greater Staff Turnover Nancy B. Lerner RN, DNP a, *, Meg Johantgen RN, PhD a, Alison M. Trinkoff RN, ScD a, Carla L. Storr ScD a, Kihye Han RN, PhD b a b
University of Maryland School of Nursing, Baltimore, MD Chung-Ang University Red Cross College of Nursing, Seoul, South Korea
a b s t r a c t Keywords: Nursing home deficiency staffing turnover nursing assistant resident outcome
Objectives: To examine CNA and licensed nurse (RNþLPN/LVN) turnover in relation to numbers of deficiencies in nursing homes. Design: A secondary data analysis of information from the National Nursing Home Survey (NNHS) and contemporaneous data from the Online Survey, Certification and Reporting (OSCAR) database. Data were linked by facility as the unit of analysis to determine the relationship of CNA and licensed nurse turnover on nursing home deficiencies. Setting: The 2004 NNHS used a multistage sampling strategy to generate a final sample of 1174 nursing homes, which represent 16,100 NHs in the United States. Participants: This study focused on the 1151 NNHS facilities with complete deficiency data. Measurements: Turnover was defined as the total CNAs/licensed nurse full-time equivalents (FTEs) who left during the preceding 3 months (full- and part-time) divided by the total FTE. NHs with high turnover were defined as those with rates above the 75th percentile (25.3% for CNA turnover and 17.9% for licensed nurse turnover) versus all other facilities. This study used selected OSCAR deficiencies from the Quality of Care, Quality of Life, and Resident Behavior categories, which are considered to be more closely related to nursing care. We defined NHs with high deficiencies as those with numbers of deficiencies above the 75th percentile versus all others. Using SUDAAN PROC RLOGIST, we included NNHS sampling design effects and examined associations of CNA/licensed nurse turnover with NH deficiencies, adjusting for staffing, skill mix, bed size, and ownership in binomial logistic regression models. Results: High CNA turnover was associated with high numbers of Quality of Care (OR 1.53, 95% CI 1.10 e2.13), Resident Behavior (OR 1.42, 95% CI 1.03e1.97) and total selected deficiencies (OR 1.54, 95% CI 1.12 e2.12). Licensed nurse turnover was significantly related to Quality of Care deficiencies (OR 2.06, 95% CI 1.50e2.82) and total selected deficiencies (OR 1.71, 95% CI 1.25e2.33). When both CNA turnover and licensed nurse turnover were included in the same model, high licensed nurse turnover was significantly associated with Quality of Care and total deficiencies, whereas CNA turnover was not associated with that category of deficiencies. Conclusion: Turnover in nursing homes for both licensed nurses and CNAs is associated with quality problems as measured by deficiencies. Ó 2014 - American Medical Directors Association, Inc. All rights reserved.
Recruitment and retention of nursing home staff to provide for the increasing number of elderly requiring care in the future is a continuing concern for nursing home administrators and nursing directors. Without a change in workforce trends, high-quality care for older Americans cannot be guaranteed.1 Turnover of nursing staff is of This study was funded by the National Council of State Boards of Nursing, grant no. R40009. The authors declare no conflicts of interest. * Address correspondence to Nancy B. Lerner, RN, DNP, 655 West Lombard Street, Rm 325A, Baltimore, MD 21201. E-mail address: [email protected] (N.B. Lerner).
concern for nursing home quality due to high annual turnover rates estimated at 46.7% (registered nurses [RNs]), 41.8% (licensed practical nurses or licensed vocational nurses [LPN/LVN]), and 46.6% (certified nursing assistants [CNAs]).2 Although turnover rates decreased somewhat for LPN/LVNs and CNAs since 2007, perhaps due to the economic recession, RN turnover has increased.3 High turnover has been associated with increased adverse resident outcomes, as reflected in higher quality indicator rates and increased rehospitalization rates.4,5 Factors other than turnover also may influence quality of care within nursing homes. Organizational factors, such as staffing and skill mix, have been related to care
1525-8610/$ - see front matter Ó 2014 - American Medical Directors Association, Inc. All rights reserved. http://dx.doi.org/10.1016/j.jamda.2013.09.003
N.B. Lerner et al. / JAMDA 15 (2014) 102e107
outcomes. Decreased rates of pressure ulcers with increased RN staffing have been well documented.6e8 Decreased restraint usage and lower rates of infection and weight loss associated with increased RN staffing also have been reported.8,9 Increased RN staffing, combined with less turnover of RNs and CNAs and limited agency use, has been associated with lower restraint usage, lower catheter and pressure sore rates, and improved pain management, whereas LPN/ LVN turnover and staffing were not associated with better quality indicators.4 In addition, licensed nurse turnover has been associated with higher rehospitalization rates for nursing home residents. 5 Despite these individual associations between organizational factors and nursing home quality, a recent systematic review of the relationship between staffing and quality found that a relationship could not be determined conclusively.10 Deficiency citations provide another measure of quality for nursing homes. The Centers for Medicare and Medicaid Services (CMS) mandates reviews of all nursing homes by teams of state-based interdisciplinary surveyors approximately once a year and follow-up of complaints received by the state survey agencies. The nursing homes are evaluated on standards developed by CMS and are given deficiencies when the facility’s performance is not in substantial compliance with the standards. Staffing and skill mix have been associated with decreased nursing home deficiencies.11,12 However, the relationship of turnover to deficiencies has not been reported since Munroe13 identified a relationship between licensed staff turnover and deficiencies more than 20 years ago. We hypothesized that in nursing homes where turnover is higher, more nursing-related deficiencies will occur. In addition, we hypothesized that after adjustment for staffing and skill mix, turnover will maintain an independent relationship to nursing-related deficiencies.
103
collected by interdisciplinary surveyors who visit each nursing home every 9 to 15 months and review care based on 180 federal regulatory standards in 15 categories. This study used OSCAR deficiency data from 2004 to coincide with the 2004 NNHS data. Sample This study focused on the 1151 facilities with complete deficiency data (23 NHs were excluded). In addition, 143 facilities had missing CNA turnover data and 139 had missing licensed nurse turnover data, and were therefore excluded from the statistical models. NH characteristics of those with and without turnover information were similar. Deficiency Outcomes This study used all deficiencies from the Quality of Care (QOC), Quality of Life (QOL), and Resident Behavior (RB) categories, which are considered to be more closely related to nursing care than categories such as administration, pharmacy, and environment.6,12 A total of 50 deficiencies were contained in these categories: 25 QOC deficiencies (eg, activities of daily living, continence, pressure ulcers and range of motion), 19 QOL deficiencies (focused on housekeeping, social service, and activities), and 6 RB deficiencies (eg, restraint use, freedom from abuse, and staff treatment of residents). A summed score of the number of deficiencies for each category (eg, QOC, QOL, RB) and an overall total were calculated. These totals were not normally distributed, so deficiency scores were dichotomized into “high” (facilities with deficiencies in that category above the 75th percentile) versus “low” (facilities with deficiencies at or below the 75th percentile in that category).
Methods
Turnover
Design and Data Sources
Two types of turnover were calculated for this study: CNA and licensed nurse turnover based on the NNHS 3-month turnover data. CNA turnover was defined as CNA FTEs for those who left during the previous 3 months (combining full- and part-time workers) divided by the total CNA FTEs.15e17 Part-time workers were defined as 0.50 FTE. Similar formulas were used to calculate licensed nurse turnover, which combined RN and licensed practical nurse FTEs (RN þ LPN/LVN). Nursing homes were categorized as having high turnover when the turnover rate exceeded the 75th percentile. Turnover included both voluntary (resignation) and involuntary (termination) separations.
The overall design was a secondary data analysis using contemporaneous information from the National Nursing Home Survey (NNHS) and the Online Survey, Certification, and Reporting (OSCAR) database. Data were linked by facility as the unit of analysis to determine the relationship of CNA and licensed nurse turnover on deficiencies thought to be sensitive to care provided by licensed and unlicensed nursing staff. The study protocol was reviewed and approved by the University of Maryland Baltimore Institutional Review Board. The 2004 National Nursing Home Survey (NNHS) is the seventh and final survey of a series about nursing homes conducted since 1973 by the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC/NCHS). The NNHS collects data on staffing levels, types, and full-time equivalents (FTEs) of practitioners, turnover, and overtime solicited from computer-assisted face-to-face interviews with nursing home administrators and staff. Additional data include type of services offered and general nursing home characteristics, such as number of beds, ownership, and resident characteristics. To select the sample of nursing homes for the 2004 NNHS, NCHS used a multistage sampling strategy, stratifying on the number of beds and metropolitan area. They then arrayed nursing homes by certification status, hospital relationship (hospital- and nonehospital-based), ownership, geographic region, state, county, and zip code.14 The final sample of 1174 homes that participated can be weighted to be representative of US nursing homes. Because our study linked NNHS turnover data to outcomes data by facility, the NNHS restricted use dataset was used. OSCAR is a CMS-maintained data network in cooperation with state long term care surveying agencies. OSCAR deficiency data were
Control Variables Staffing and skill mix were included in the analysis as control variables and were obtained from the NNHS database for CNAs, licensed nurses (RN þ LPN/LVN), and total staffing. Total staffing was equal to the RN, LPN/LVN, CNA, and aides’ total hours per resident day (HPRD)17 and was dichotomized as greater than 5.0 HPRD or not. Skill mix was defined as the licensed nurse (RN þ LPN/LVN) FTEs divided by all total staffing FTEs (RN, LPN/LVN, CNA, aides). In addition, control variables included nursing home characteristics, such as facility size (3e49, 50e99, 100e199 versus 200 beds) and ownership (for-profit versus all others) obtained from the NNHS. Criteria for control variables were based on prior definitions found in the literature.9,17,18 Data Analysis Analyses were conducted on the merged data after obtaining approval from the NCHS Research Data Center (RDC). Sampling
104
N.B. Lerner et al. / JAMDA 15 (2014) 102e107
Table 1 Study Nursing Home Characteristics, Weighted, 2004 National Nursing Home Survey (NNHS)
Unweighted no. of nursing homes Weighted no. of nursing homes represented Three-month turnover, % CNA, mean (95% CI), range Licensed nurse, mean (95% CI), range Skill mix (licensed nurse proportion, %), mean (95% CI), range Nurse staffing, n (%) 5 hours per resident day <5 hours per resident day No. of beds, n (%) 3e49 50e99 100e199 200 Ownership, n (%) For-profit All others Affiliation, n (%) Chain Independent Occupancy rate, n (%) <70% 70%e79% 80%e89% 90%e94% 95%
NNHS Nursing Homes
NHs With Deficiency Data
1174 16362
1151 16040
16.2 (15.1e17.2), 0.0e182.8 11.6 (10.6e12.5), 0.0e200.0 33.9 (33.4e34.5), 9.8e100.0
16.2 (15.1e17.2), 0.0e182.8 11.7 (10.7e12.6), 0.0e200.0 33.9 (33.4e34.5), 9.8e100.0
1728 (12.0) 12708 (88.0) 2295 6168 6876 1023
1632 (11.5) 12509 (88.5)
(14.0) (37.7) (42.0) (6.3)
2173 6041 6818 1008
(13.6) (37.7) (42.5) (6.3)
10079 (61.6) 6283 (38.4)
9990 (62.3) 6050 (37.7)
8863 (54.2) 7499 (45.8)
8770 (54.7) 7270 (45.3)
2055 1888 3700 3065 5654
1906 1861 3654 3029 5590
(12.6) (11.5) (22.6) (18.7) (34.6)
(11.9) (11.6) (22.8) (18.9) (34.9)
CI, confidence interval; CNA, certified nursing assistant.
weights were applied using SUDAAN (Research Triangle Institute International, Research Triangle Park, NC) to correct for design effects of the complex sampling strategy used in the NNHS. Although these data underwent extensive cleaning before release, additional data quality and completeness checks were conducted, and frequencies were compared with benchmarks from the nonconfidential (public use) NNHS data. Associations were explored and model assumptions tested using SAS-callable SUDAAN (version 10.0.1) PROC RLOGIST. Each category of deficiencies was modeled separately and again as a total of all included deficiencies. Three sets of models were generated, one for CNA turnover, the second for licensed nurse turnover, and the third set contained both CNA and licensed nurse turnover in relation to deficiencies. After first noting crude associations (bivariate), models were then adjusted for staffing, skill mix, number of beds, and ownership. Similar results were obtained when turnover
was modeled as a continuous and categorical variable. Based on better model fit, we present the findings from the categorical models, comparing those with high deficiencies (above 75th percentile to all others). Results As shown in Table 1, estimated CNA turnover for a 3-month period was 16.2% (95% confidence interval [CI] 15.1e17.2; range, 0.0e182.8) and licensed nurse turnover was 11.7% (95% CI 10.7e12.6; range, 0.0e200.0). Most NHs had total HPRD below 5 (88.5%), were for-profit (62.3%); 54.7 % were chain affiliated. Most NHs had between 50 and 199 beds (80.2%) with only 6.3% of facilities having 200 or more beds. CNA turnover was related to nursing care deficiencies (Table 2), with high turnover increasing the odds of having high total
Table 2 Estimated Associations Between CNA Turnover and Nursing Care Deficiencies in a Representative Sample of US Nursing Homes (n ¼ 1151) Total Nursing Care Deficiencies*
Quality of Care Deficiencies*
Quality of Life Deficiencies*
Resident Behavior Deficiencies*
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
1.14e2.10
1.52
1.11e2.09
1.24
0.85e1.82
1.36
1.00e1.86
1.16e2.16 0.78e1.86 0.97e0.99
1.51 0.94 0.98
1.09e2.08 0.59e1.52 0.97e1.00
1.25 1.19 0.98
0.85e1.85 0.69e2.07 0.96e1.00
1.43 1.41 0.99
1.04e1.97 0.91e2.17 0.97e1.00
1.12e2.12 0.78e1.89 0.97e1.00 0.24e0.95 0.32e1.04 0.48e1.52 0.84e1.54
1.53 0.94 0.99 0.56 0.62 0.91 0.95
1.10e2.13 0.58e1.52 0.97e1.00 0.28e1.13 0.33e1.13 0.50e1.65 0.70e1.28
1.16 1.24 0.99 0.30 0.64 0.54 1.29
0.78e1.72 0.71e2.14 0.96e1.01 0.12e0.73 0.32e1.25 0.27e1.05 0.89e1.88
1.42 1.42 0.99 0.93 0.97 0.88 1.03
1.03e1.97 0.92e2.18 0.97e1.00 0.47e1.87 0.53e1.80 0.48e1.63 0.76e1.40
Model 1: crude association CNA turnover,y high vs low 1.54 Model 2: adjusted for staffing and skill mix y 1.58 CNA turnover, high vs low Nurse staffing, 5 HPRD vs <5 HPRD 1.20 Skill mix, licensed nurse proportion 0.98 Model 3: also adjusting for nursing home characteristics 1.54 CNA turnover,y high vs low Nurse staffing, 5 HPRD vs <5 HPRD 1.21 Skill mix, licensed nurse proportion 0.99 No. of beds, <50 vs 200 0.48 50e99 vs 200 0.58 100e199 vs 200 0.85 Ownership, for profit vs not 1.14
CI, confidence interval; CNA, certified nursing assistant; HPRD, hours per resident day; OR, odds ratio. *>75th percentile (vs 75th percentile) for number of deficiencies. y Turnover high (>75th percentile) and low (75th percentile).
N.B. Lerner et al. / JAMDA 15 (2014) 102e107
105
Table 3 Estimated Associations Between Licensed Nurse (RN þ LPN/LVN) Turnover and Nursing Care Deficiencies in a Representative Sample of US Nursing Homes (n ¼ 1151) Total Nursing Care Deficiencies*
Quality of Care Deficiencies*
Quality of Life Deficiencies*
Resident Behavior Deficiencies*
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
1.29e2.36
2.10
1.55e2.85
1.48
1.02e2.14
1.23
0.90e1.68
1.27e2.35 0.79e1.90 0.97e1.00
2.04 1.02 0.98
1.49e2.78 0.63e1.65 0.97e0.99
1.46 1.25 0.98
0.99e2.13 0.72e2.16 0.96e0.99
1.25 1.37 0.99
0.91e1.71 0.89e2.10 0.97e1.00
1.25e2.33 0.80e1.95 0.97e1.01 0.23e0.90 0.32e1.02 0.46e1.44 0.86e1.57
2.06 1.02 0.99 0.53 0.59 0.86 0.94
1.50e2.82 0.62e1.65 0.97e1.00 0.26e1.07 0.32e1.08 0.47e1.55 0.69e1.28
1.44 1.32 0.99 0.29 0.62 0.52 1.28
0.98e2.12 0.76e2.28 0.97e1.01 0.12e0.71 0.32e1.22 0.26e1.01 0.88e1.85
1.24 1.38 0.99 0.91 0.97 0.87 1.07
0.90e1.71 0.90e2.13 0.97e1.00 0.46e1.81 0.53e1.80 0.47e1.59 0.79e1.44
Model 1: crude association 1.75 Licensed nurse turnover,y high vs low Model 2: adjusted for staffing and skill mix 1.72 Licensed nurse turnover,y high vs low Nurse staffing, 5 HPRD vs <5 HPRD 1.22 Skill mix, licensed nurse proportion 0.98 Model 3: also adjusting for nursing home characteristics y 1.71 Licensed nurse turnover, high vs low Nurse staffing, 5 HPRD vs <5 HPRD 1.25 Skill mix, licensed nurse proportion 0.99 Number of beds, <50 vs 200 0.45 50e99 vs 200 0.57 100e199 vs 200 0.81 Ownership, for profit vs not 1.16
CI, confidence interval; HPRD, hours per resident day; LPN/LVN, licensed practical nurse or licensed vocational nurse; OR, odds ratio; RN, registered nurse. *>75th percentile (vs 75th percentile) for number of deficiencies. y Turnover high (>75th percentile) and low (75th percentile).
deficiencies by 54% (OR 1.54, 95% CI 1.14e2.10). By deficiency category, associations were strongest for QOC (OR 1.52, 95% CI 1.11e2.09) and RB (OR 1.36, 95% CI 1.00e1.86) deficiencies but did not reach significance for the QOL category. The significant relationships did not change when control variables were added. Lower skill mix was also significantly related to more total deficiencies (OR 0.98, 95% CI 0.97e0.99), but not when bed size and ownership were added to the model. Licensed nurse turnover was also significantly related to total deficiencies (OR 1.75, 95% CI 1.29e2.36) and QOC deficiencies (OR 2.10, 95% CI 1.55e2.85), even after control variables were added to the model (Table 3). Skill mix was significantly associated with QOC and QOL deficiencies (OR 0.98, 95% CI 0.97e0.99), but these relationships were no longer significant when number of beds and ownership were controlled (model 3). When CNA and licensed nurse turnover were included in the same model (Table 4), high licensed nurse turnover was significantly associated with QOC deficiencies (OR 1.92, 95% CI 1.38e2.69) and total deficiencies (OR 1.56, 95% CI 1.12e2.17), whereas CNA turnover was not associated with that category of deficiencies.
These findings were the same with and without the inclusion of control variables. Discussion High CNA turnover was related to higher numbers of QOC, RB, and total deficiencies in nursing homes, and these associations remained after adjustment. CNA turnover was not associated with QOL deficiencies. Although CNA turnover has been associated with poor quality indicators in nursing homes and poor end-of-life care,4,19,20 this is the first study to find CNA turnover was related to deficiencies. The QOC deficiencies include activities of daily living, continence, pressure ulcers, and range of motion, all of which involve tasks primarily performed by CNAs. The deficiencies dealing with resident behavior also depend on knowledgeable CNA care, as they deal with restraints, freedom from abuse, and staff treatment of residents. The lack of familiarity with residents and their requirements that can accompany CNA turnover would be expected to adversely affect care in these categories. Conversely, QOL deficiencies also involve work by other providers, such as housekeeping, social service, and activity
Table 4 Estimated Associations Between Nursing Staff Turnover and Nursing Care Deficiencies in a Representative Sample of US Nursing Homes (n ¼ 1151)
Model 1 CNA turnover,y high vs low Licensed nurse turnover,y high vs low Model 2 CNA turnover,y high vs low Licensed nurse turnover,y high vs low Nurse staffing, 5 HPRD vs <5 HPRD Skill mix, licensed nurse proportion Model 3 CNA turnover,y high vs low Licensed nurse turnover,y high vs low Nurse staffing, 5 HPRD vs <5 HPRD Skill mix, licensed nurse proportion Number of beds, <50 vs 200 50e99 vs 200 100e199 vs 200 Ownership, for profit vs not
Total Nursing Care Deficiencies*
Quality of Care Deficiencies*
Quality of Life Deficiencies*
Resident Behavior Deficiencies*
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
1.34 1.59
0.97e1.86 1.15e2.19
1.22 1.96
0.87e1.72 1.41e2.72
1.10 1.43
0.73e1.66 0.96e2.13
1.32 1.12
0.95e1.84 0.81e1.56
1.38 1.57 1.28 0.98
0.99e1.92 1.13e2.17 0.83e1.99 0.97e1.00
1.23 1.91 1.04 0.99
0.87e1.74 1.37e2.66 0.64e1.69 0.97e1.00
1.12 1.40 1.25 0.98
0.74e1.71 0.93e2.10 0.72e1.29 0.96e1.00
1.38 1.13 1.43 0.99
0.99e1.92 0.81e1.57 0.93e2.21 0.97e1.00
1.34 1.56 1.29 0.99 0.46 0.56 0.82 1.12
0.96e1.89 1.12e2.17 0.82e2.03 0.97e1.01 0.23e0.91 0.31e1.01 0.46e1.46 0.83e1.52
1.25 1.92 1.03 0.99 0.53 0.59 0.86 0.92
0.88e1.78 1.38e2.69 0.63e1.69 0.97e1.01 0.26e1.07 0.32e1.08 0.48e1.55 0.68e1.25
1.03 1.42 1.31 0.99 0.29 0.62 0.52 1.28
0.68e1.57 0.94e2.14 0.75e2.28 0.97e1.01 0.12e0.71 0.32e1.22 0.26e1.02 0.88e1.86
1.37 1.13 1.44 0.99 0.93 0.97 0.87 1.03
0.98e1.92 0.81e1.58 0.93e2.22 0.97e1.00 0.46e1.86 0.52e1.79 0.47e1.61 0.76e1.39
CI, confidence interval; CNA, certified nursing assistant; HPRD, hours per resident day; OR, odds ratio. *>75th percentile (vs 75th percentile) for number of deficiencies. y Turnover high (>75th percentile) and low (75th percentile).
106
N.B. Lerner et al. / JAMDA 15 (2014) 102e107
staff in addition to CNAs, thus the lack of an association between CNA turnover and deficiencies in this category is not surprising. The influence of licensed nurse turnover on total and QOC deficiencies even after adjustment for staffing, skill mix, bed size and ownership, mirrors the 1990 results of Munroe,13 who identified an association between licensed staffing and quality in a model that he developed. Licensed nurse turnover has likewise been associated with decreased quality of care in nursing facilities, as demonstrated by CMS Quality Indicators.4,9,19 Licensed nurse turnover was also a factor in the quality of end-of-life care in nursing facilities21 and has been shown to be a factor in rehospitalization rates for nursing home patients.5 Although we hypothesized that turnover would increase the odds of deficiencies, we did not expect the strength of CNA turnover when licensed turnover was included in the model. For total and RB deficiencies, only CNA turnover remained significant when the other variables were all entered into the model. In nursing facilities, patient care is largely dependent on the CNA staff. 21,22 Consistent assignment of nursing assistants to the same patient has been associated with improved quality of care.23,24 Recently, consistent assignment also was associated with reduced turnover and with decreased deficiencies, so as a mechanism for reduced turnover and improved care quality it should be further examined.25 Other factors found to be associated with low turnover of CNA staff include organizational factors, such as staffing, wages, and involvement in care planning and positive work relationships.26,27 On the other hand, for QOC deficiencies, licensed nurse turnover was the more important factor. This is logical because many QOC deficiencies include domains for which licensed providers are responsible, such as medications, nasogastric tube care, nutrition, and hydration. They are noted as F-tags, that is, deficiencies that relate to CMS care standards, with the F-tag matching the number for the CMS care standard.28 In addition, F-tag 309, “Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care,”28 specifically relates to assessing, planning, and implementing care under the purview of licensed nursing staff. Limitations This study was limited by the use of cross-sectional data and that both the NNHS and OSCAR data were collected in 2004, the latest year for which the NNHS data are available. The exclusion of some facilities because of unavailable data also may have affected the findings. Therefore, despite a good participation rate and limited missing data in both surveys, caution must be taken in generalizing results to all facilities. The analysis of deficiencies was also limited through selection of deficiencies from 3 categories, although these were chosen based on previous research that identified the selected deficiencies as those most likely to be nursingsensitive. Our findings also may have been influenced by the use of deficiencies as a dependent variable, because reported deficiencies are dependent on the surveyors performing the actual survey and wide variation has been identified between different teams of surveyors and across states.29 Surveyor variation has also been found in stipulating which specific regulation a nursing home did not meet, although agreement existed in the number of deficiencies.30 Conclusion Turnover in nursing homes for both licensed nurses and CNAs is an ongoing problem that also impacts the quality of care for nursing
home residents. Continued research using deficiencies as a measure of quality, in addition to the quality indicators used by others, should be beneficial. In addition, easily accessible resources are needed for nursing home administrators and directors of nursing to help them address the relationship between turnover and quality and to assist with creating a more stable care environment. More study on interventions that lower nursing home turnover for all levels of staff is sorely needed, along with dissemination of interventions shown to reduce turnover. References 1. Institute of Medicine. Retooling for an aging America: Building the healthcare workforce. 2008. Available at: http://www.iom.edu/Reports/2008/Retooling-foran-Aging-America-Building-the-Health-Care-Workforce.aspx. Accessed May 15, 2013. 2. American Health Care Association. LTC stats: Nursing facility operational characteristics report. 2011. Available at: http://www.ahcancal.org/research_ data/oscar_data/Nursing%20Facility%20Operational%20Characteristics/Operational CharacteristicsReport_Dec2011.pdf. Accessed May 15, 2013. 3. American Health Care Association. Report of findings 2007 AHCA survey: Nursing staff vacancy and turnover in nursing facilities. 2008. Available at: http://www. ahcancal.org/research_data/staffing/Documents/Vacancy_Turnover_Survey2007. pdf. Accessed May 15, 2013. 4. Castle NG, Anderson RA. Caregiver staffing in nursing homes and their influence on quality of care: Using dynamic panel estimation methods. Med Care 2011;49:545e552. 5. Thomas KS, Mor V, Tyler DA, Hyer K. The relationships among licensed nurse turnover, retention, and rehospitalization of nursing home residents. Gerontologist 2013;53:211e221. 6. Bowblis JR. Staffing ratios and quality: An analysis of minimum direct care staffing requirements for nursing homes. Health Serv Res 2011;46:1495e1516. 7. Horn SD, Buerhaus P, Bergstrom N, Smout RJ. RN staffing time and outcomes of long-stay nursing home residents: Pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care. Am J Nurs 2005; 105:58e70. 8. Weech-Maldonado R, Meret-Hanke L, Neff MC, Mor V. Nurse staffing patterns and quality of care in nursing homes. Health Care Manage Rev 2004;29: 107e116. 9. Castle NG, Engberg J. Staff turnover and quality of care in nursing homes. Med Care 2005;43:616e626. 10. Spilsbury K, Hewitt C, Stirk L, Bowman C. The relationship between nurse staffing and quality of care in nursing homes: A systematic review. Int J Nurs Stud 2011;48:732e750. 11. Harrington C, Olney B, Carrillo H, Kang T. Nurse staffing and deficiencies in the largest for-profit nursing home chains and chains owned by private equity companies. Health Serv Res 2012;47:106e128. 12. Kim H, Kovner C, Harrington C, et al. A panel data analysis of the relationships of nursing home staffing levels and standards to regulatory deficiencies. J Gerontol B Psychol Sci Soc Sci 2009;64:269e278. 13. Munroe DJ. The influence of registered nurse staffing on the quality of nursing home care. Res Nurs Health 1990;13:263e270. 14. CDC/National Center for Health Statistics. The National Nursing Home Survey: 2004 overview. 2009. Available at: http://www.cdc.gov/nchs/data/series/sr_ 13/sr13_167.pdf. Accessed May 15, 2013. 15. Castle NG. Measuring staff turnover in nursing homes. Gerontologist 2006;46: 210e219. 16. Donoghue C. Nursing home staff turnover and retention: An analysis of national level data. J Appl Gerontol 2010;29:89e106. 17. Temple A, Dobbs D, Andel R. Exploring correlates of turnover among nursing assistants in the National Nursing Home Survey. Health Care Manage Rev 2009; 34:182e190. 18. Decker FH, Castle NG. Relationship of the job tenure of nursing home top management to the prevalence of pressure ulcers, pain, and physical restraint use. J Appl Gerontol 2010;30:539e561. 19. Castle NG, Engberg J, Men A. Nursing home staff turnover: Impact on nursing home compare quality measures. Gerontologist 2007;47:650e661. 20. Tilden VP, Thompson SA, Gajewski BJ, et al. Sampling challenges in nursing home research. J Am Med Dir Assoc 2013;14:25e28. 21. McConnell ES, Lekan D, Corazzini KN. Assuring the adequacy of staffing of longterm care, strengthening the caregiving workforce, and making long-term care a career destination of choice: from mission impossible to mission critical? N C Med J 2010;71:153e157. 22. Houser A, Fox-Grage W, Gibson MJ. Across the States 2009: Profiles of LongTerm Care and Independent Living. 8th ed. Washington, DC: AARP Public Policy Institute; 2009. 23. Scandrett KG, Anichini MA, Berdes C, et al. Patient safety in the nursing home: How nursing staff assess and communicate about change in condition. J Gerontol Nurs 2012;38:28e37. 24. Castle NG. Consistent assignment of nurse aides: Association with turnover and absenteeism. J Aging Soc Policy 2013;25:48e64.
N.B. Lerner et al. / JAMDA 15 (2014) 102e107 25. Castle NG. The influence of consistent assignment on nursing home deficiency citations. Gerontologist 2011;51:750e760. 26. Dill DM, Keefe JM, McGrath DS. The influence of intrinsic and extrinsic job values on turnover intention among continuing care assistants in Nova Scotia. Home Health Care Serv Q 2012;31:111e129. 27. Temple A, Dobbs D, Andel R. Exploring correlates of turnover among nursing assistants in the national nursing home survey. J Nurs Adm 2011;41:S34eS42. 28. CMS Manual System Department of Health & Human Services (DHHS) Pub. 10007 State Operations Provider Certification: F tag 309—Quality of Care- Advance
107
Copy. Available at: http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter12-48.pdf. Accessed October 1, 2013. 29. Office of the Inspector General. Nursing home deficiency trends and survey and certification process consistency. 2003. Available at: http://oig.hhs.gov/oei/ reports/oei-02-01-00600.pdf. Accessed May 15, 2013. 30. Lee RH, Gajewski BJ, Thompson S. Reliability of the nursing home survey process: A simultaneous survey approach. Gerontologist 2006;46: 772e779.