Nursing Home Staff Turnover and Perceived Patient Safety Culture: Results from a National Survey

Abstract

Background and objectives: We examined the association between turnover of registered nurses (RNs) and certified nurse assistants (CNAs) and perceived patient safety culture (PSC) in nursing homes (NHs).

Research design and methods: In 2017, we conducted PSC survey using the Agency for Healthcare Research and Quality- developed and -validated instrument for NHs. A random sample of 2,254 U.S. NHs was identified. Administrators, directors of nursing (DONs), and nurse unit leaders served as respondents. Responses were obtained for 818 facilities from 1,447 individuals. The instrument contained 42 items relating to 12 PSC domains and turnover rates. PSC domains were based on five-point Likert scale items. A positive response was defined as "agree" or "strongly agree" (4-5 on the Likert scale). For CNAs low turnover was defined as <35%, and for RNs <15%. Facility-level and market-competition characteristics were included. Bivariate comparisons employed analysis of variance and chi-square tests. In multivariable models, we fit separate linear regressions for the average positive PSC score and for each of the 12 PSC domains, including turnover rates, NH, and market factors.

Results: In NHs with low turnover, the overall PSC scores were 4.04% (RNs) and 6.28% (CNAs) higher than in NHs with high turnover. Teamwork, staffing, and training/skills were associated with CNA but not RN turnover.

Discussion and implications: The effect of turnover on PSC depends on who leaves and to a lesser extent on the organizational characteristics. In NHs, improvements in PSC may depend on the ability to retain a well-trained and skilled nursing staff.

Keywords: Nursing homes; Patient safety culture; Turnover.