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Turnover of licensed nurses in skilled nursing facilities.

Executive Summary

* Like hospitals, skilled nursing facilities (SNFs) face increasing cost and regulatory pressure, but they have also experienced greater turnover rates among staff and bear the brunt of the population growth among the elderly.

* The researchers examined the relationship between staff turnover and several other variables such as demographics about the DON, facility variables, and staffing patterns.

* The educational preparation and tenure of the DON, salaries, opportunities for advancement, for/not-for-profit status, and location did not have a significant relationship with turnover rates.

* The size of the facility showed a nearly significant relationship with turnover, with larger SNFs having higher turnover rates.

* DONs perceived that pay/benefits, work environment, and teamwork were factors in retention, while poor pay/benefits, schedule conflicts, and relocation were perceived as drivers of turnover.

* The authors noted DONs and administrators have the ability to control the majority of the perceived factors influencing retention and turnover.

ADVANCES IN DISEASE control and health care technology have dramatically increased the life expectancy for Americans. According to the U.S. Department of Commerce (1993), in the 1920s the average life expectancy was 54.1 years. By 1965, the figure had jumped to 70.2 years, and it is projected to be 77.6 years by the year 2010.

Current estimates indicate that there are approximately 16 million people in the United States over age 65. Projections for the year 2030 for this age group vary greatly: from 31 million (Knapp, 1997), to 64 million (Ross & Wright, 1998), to 70 million (U.S. Department of Commerce, 1993).

As more of this group live longer, there will be a growing number of frail, chronically ill, elderly people in need of health care. Currently, less than 5% of the elderly population reside in nursing homes or skilled nursing facilities (SNFs). However, approximately 25% will spend some time in a SNF during the last years of life (Swanson & Tripp-Reimer, 1997). Because of the unprecedented number of people who are living longer, there will be dramatic increases in the number of persons utilizing SNFs (Ross & Wright, 1998).

SNFs now provide complex treatments and therapies for geriatric patients including intravenous therapy (IV therapy), peritoneal dialysis, tracheostomy care, and respirator care. SNFs have not provided this kind of acute care in the past, and they are struggling to meet these demands for a growing patient population. In addition, regulatory and financial restrictions are forcing administrators to push the nursing staff to "do more with less."

As a result SNFs typically have higher nursing turnover rates than hospitals and other settings where nurses are employed (Mesirow, Klopp, & Olson, 1998). According to Cohen-Mansfield (1997), turnover among nursing staff in SNFs ranges from 40% to 75%, and can go as high as 500%. According to R. Jenkins, director of policy development, North Carolina Health Care Facility Association, in 1997 SNF turnover rates in North Carolina were as follows: registered nurses (RNs) = 71%, licensed practical nurses (LPNs) = 53%, and nursing assistants (NAs) = 99% (personal communication, February 3, 1999). Compounding the turnover problem facing SNFs is the fact that we are now facing a nursing shortage that will only worsen with the turn of the century (Curtin, 1998). As the population ages, their use of SNFs increases and patient acuity in SNFs increases. It is clear that there is a crisis with staffing in SNFs.

The costs (both direct and indirect) of turnover have been studied by many researchers in both acute and nonacute settings. The cost to replace a RN in an outpatient setting was estimated by Bame (1993) to be more than $10,000. According to Jones (1990), the cost to replace a RN employed in a hospital is also over $10,000. Caudill and Patrick (1991) noted that replacing an RN in a SNF could cost over $7,000. Given the scarce resources available in SNFs, the cost of replacing RNs in a SNF can spell disaster.

Little research has examined the turnover of licensed nurses in SNFs. However, several studies have examined turnover of certified nurse assistants (CNAs) and some of the reasons for CNA turnover in SNFs might be the same for the turnover of licensed nurses in SNFs. Mesirow et al. (1998) found that meeting CNA's security needs resulted in decreased turnover. They also found that increasing involvement in patient care and in work life decisions positively affected employee satisfaction and reduced turnover. Brannon, Cohn, and Smyer (1990) and Helmer, Olson, and Heim (1993) found that CNA turnover in SNFs was related to dissatisfaction with salary. Caudill and Patrick (1989) found a relationship between CNA turnover and salary, benefits, and feedback from residents, peers, and staff. And Holtz (1982) found that interpersonal relationships positively affected work satisfaction and turnover among CNAs in SNFs.

Robertson, Herth, and Cummings (1994) examined nurse satisfaction in SNFs. Five issues emerged as pertinent to work satisfaction in SNFs: relationships (with patients and families), patient care factors, money and benefits, adequacy of staffing and supplies, and the amount of paperwork. Cart and Kazanowski (1994), who compared gerontologic nurses in SNFs to gerontologic nurses employed elsewhere, concluded that nurses in SNFs were more dissatisfied than nurses elsewhere. Reasons cited for dissatisfaction were poor staff cohesion in SNFs, poor staffing, tremendous workload, and poor working relationship with administrators.

Chambers (1990) examined the ability of three attributes of SNFs to predict turnover of licensed nurses. The first attribute, organizational characteristics, included size, location, ownership, opportunity, pay, care type, and volunteers. Chambers concluded that large, noncorporate, rural organizations had lower turnover rates. Facilities that employed nurses who were younger, had a higher educational level, worked part time, and/or worked rotating shifts had higher turnover rates. Facilities with a "closed climate" had higher turnover rates.


With managed care, downsizing, increased regulatory constraints, a growing national nursing shortage, and costly turnover in SNFs, a careful examination of factors that contribute to turnover is essential. Yet few recent studies have examined nurse turnover in SNFs. The purpose of this study was to identify trends and factors contributing to turnover of licensed nurses in SNFs in North Carolina.

Specifically, this study examined the turnover rates of licensed nurses in SNFs in North Carolina, the relationship between the educational level of the director of nursing (DON) and the turnover of licensed nurses in SNFs, the relationship between the length of time the DON had been in his/her position and the turnover of licensed nurses in SNFs, and the relationship between the salary of licensed nurses and the turnover rates in SNFs. The study also looked at whether differences in turnover rates existed between agencies that provided opportunities for advancement and personal growth in SNFs and agencies that did not, between large facilities and small facilities, between for-profit and not-for-profit SNFs, and between SNFs located in urban areas and rural areas of the state. Data provided by DONs in SNFs were analyzed for common themes and patterns.


Data were requested from the 403 DONs in SNFs in North Carolina during the Fall of 1999. Mailing labels of the complete list of all North Carolina SNFs were secured from the Department of Health and Human Services, Division of Facility Services. The DONs were mailed a cover letter, a questionnaire, and a self-addressed, stamped envelope in which to return the questionnaire.

A reminder letter was faxed to all DONs surveyed approximately 4 weeks after the first mailing to maximize the response rate. Anonymity of the respondents was assured; no codes or numbers were used anywhere on either the tool or the envelopes. The study was approved by the appropriate institutional review board.

The questionnaire had three categories of questions: demographic data about the DON, information about the facility, and facts about the facility's staffing patterns (acuity level, salaries, benefits, and the turnover of licensed nurses). Content validity for the questionnaire was assured by having five experts in SNFs critique the tool.


Of the 403 questionnaires mailed to DONs, 83 were returned for a 21% return rate. The turnover rate in their facilities is shown in Table 1. To evaluate turnover rates among different groups, nurses were grouped into: full-time RNs, part-time RNs, full-time LPNs, and part-time LPNs and turnover rates were calculated for these groups, as well as for the entire group of licensed nurses.

Table 1 shows that full-time RN turnover rates ranged from 0 to 250% and part-time RN turnover rates ranged from 0 to 120%. Full-time LPN turnover rates ranged from 0 to 150%, while part-time LPN turnover rates were the highest in the group with a 500% turnover rate. The mean turnover rate of licensed nurses was 116.7%.

The relationships between the educational level and tenure of the DON and the mean turnover rate were examined using Spearman's rho correlation coefficient. There were no significant associations between mean turnover rate and the educational level of the DON or the tenure of the DON. Also, when the salaries of LPNs and RNs were examined in relation to the mean turnover rates of LPNs and RNs, using Pearson's correlation, there were no significant associations (see Table 2).

The relationships between mean turnover rate and four characteristics of SNFs were then examined: opportunities for advancement, size, financial classification, and location. There were no significant associations between turnover rate and opportunities for advancement, financial classification, and the location of the SNFs. However, the relationship between turnover rate and size neared significance with a p value of .055. The larger the SNF, the higher the turnover rate.

DONs were asked to list in rank order their views of the top reasons why nurses stayed employed and why there was turnover. This was a fill-in-the-blank question and items that seemed very similar were grouped together (for example, pay, money, good wages, etc.). The answers to each question were then compiled, tallied based on a point system in which reasons ranked #1 were given 3 points, reasons ranked #2 received 2 points, and third ranked reasons received 1 point. The answers are listed in order of their weighted ranks in Tables 3 and 4.

According to the DONs who returned surveys, the top reason that nurses stayed employed was good pay/benefits, followed by a good work environment, and teamwork/peer support. While a total of 33 reasons were given for nurses staying employed, only reasons with a weighted ranking of 11 or greater are listed in Table 3. Interestingly, the top six reasons that the DONs gave for nurses staying employed can all be influenced by the owners and nursing leaders of SNFs. Owners can invest in better salaries and benefits for licensed nurses. Nursing leaders could develop and foster a good work environment where teamwork is encouraged. Supportive management, along with flexibility in scheduling, should also yield lower turnover rates and lead to positive patient outcomes.

As shown in Table 4, the top three reasons these DONs thought there was turnover of licensed nurses were low salary/benefits, schedule conflict, and moving/relocation. A total of 31 reasons were given by the DONs; however, only reasons weighted 8 or greater are included in Table 4.


The most useful information from this study is the DONs' opinions of the reasons why licensed nurses stay employed and why they leave. Of course, this information may or may not accurately reflect the opinions of licensed nurses, and since only 83 of the 403 DONs (21%) returned their questionnaires, there is no way of knowing what the remaining 79% of the DONs might have reported. Nevertheless, these data mirror some of the findings cited in previous studies. Carr and Kazanowski (1994), for example, concluded that the major reasons for dissatisfaction among nurses were poor staff cohesion, poor staffing, tremendous workload, and poor working relationships with administrators. Similar reasons for turnover rates of nurses were given by DONs in this study.

Also, Chambers (1990) found that part-time nurses had higher turnover rates than full-time nurses. Similar results were found for LPNs in this study: full-time LPN turnover was 150% but part-time LPN turnover was 500%. For RNs, however, full-time turnover (250%) was greater than part-time turnover (120%).

Robertson et al. (1994) found five issues pertinent to work satisfaction: relationships with patients/families, patient care factors, money and benefits, adequacy of staffing and supplies, and the amount of paperwork. The reasons given in Table 3 for nurses continued employment are similar to those found by Robertson et al. (1994). Three of the five reasons cited by Robertson et al. are among the DONs' opinions of the top 10 reasons why nurses stay employed: good pay/benefits, acuity/low nurse-to-patient ratio/good staffing, and having a close relationship with the patients.


Turnover has tremendous effects on health care organizations. The problem for SNFs borders on crisis, and a thorough understanding of the factors that influence turnover is necessary for nursing leaders and SNF owners to develop solutions. This study suggests that DONs think the major reasons for turnover in SNFs relate to money: salaries, benefits, and poor nurse/patient ratios. Owners and nursing leaders of SNFs have the power and influence to alter some of these important factors in turnover of nurses. Owners must invest more money in better salaries and benefits. They can also provide the funding for more licensed nurses, which would yield better staffing ratios. As the population ages and the numbers of people needing SNFs multiply, it is imperative that changes are made to assure adequate staffing of SNFs. Nursing leaders can affect the work environment by being supportive leaders, fostering teamwork, offering flexibility with scheduling, and creating programs like a career ladder that would offer challenging work and opportunities for advancement.
Table 1.

Turnover Rates in Skilled Nursing Facilities in North Carolina
(n = 83)

           Full-Time   Part-Time   Full-Time   Part-Time   Mean to
           RN          RN          LPN         LPN         Mean
           Turnover    Turnover    Turnover    Turnover    Turnover

Mean        40.271      31.833      30.521      44.872      37.550
SD          41.050      32.250      40.912      74.453      29.210
Range      250         120         150         500         116.7
Minimum    0           0           0           0           0
Maximum    250         120         150         500         500
Table 2.

Relationships Between Mean Annual Turnover Rates of Licensed
Nurses and Characteristics of Skilled Nursing Facilities

Characteristics of SNF (a)        n       r       p

Education of DON (a)              70    -.019    .439
Tenure of DON (a)                 70    -.029    .405
Mean RN salary (b)                63     .097    .237
Mean LPN salary (b)               63    -.022    .437

* p < .05

a = Spearman's rho

b = Pearson's r
Table 3.

Directors of Nursings' Top Reasons Why Licensed
Nurses Stayed Employed

Reasons                                                        Ranking

 1. Good pay/benefits                                             124
 2. Good work environment                                          53
 3. Teamwork/peer support                                          46
 4. Schedule flexibility/straight shifts                           38
 5. Acuity/low nurse-to-patient ratio                              35
 6. Supportive management/stable DON                               34
 7. Location/area/close proximity to home                          23
 8. Family atmosphere/friendly atmosphere                          21
 9. Close relationship with patients/like the patients             14
10. Job security                                                   11
Table 4.

Director of Nursings' Opinions of Reasons for Turnover
of Licensed Nurses

Reasons                                                        Ranking

 1. Low salary/benefits                                           76
 2. Schedule conflict                                             58
 3. Moved/relocated                                               57
 4. Overworked/short staffed/patient-nurse ratio/pressure         51
 5. Little opportunity for advancement/hospital opportunity       50
 6. Poor quality of work/unable to meet standards                 19
 7. Burnout                                                       16
 8. Poor leadership/support                                       14
 9. Dislike of LTC/unable to adapt to LTC                         13
10. Too much paperwork                                             8


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TERESA P. THOMPSON, MSN, RNC, is Clinical Research Nurse, Oncology Administration, Moses Cone Health Center, Greensboro, NC.

HAZEL N. BROWN, EdD, RNC, CNAA, is Professor, School of Nursing, The University of North Carolina at Greensboro, Greensboro, NC.
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Author:Thompson, Teresa P.; Brown, Hazel N.
Publication:Nursing Economics
Geographic Code:1USA
Date:Mar 1, 2002
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