Every month, the leadership team at the Gerontological Advanced Practice Nurses Association (GAPNA) highlights the most important published literature that impacts geriatric practice. This month, Valerie K. Sabol, PhD, MBA, ACNP, GNP, ANEF, FAANP, FAAN, discusses how staffing issues in nursing homes influences quality of care for patients.

Facility-Level Factors Associated With CNA Turnover and Retention: Lesson for the Long-Term Services Industry

Gerontologist. 2020;60(8):1436-1444.

Using data from the Ohio Biennial Survey of Long-Term Care Facilities, Ohio Medicaid Cost Reports, Certification and Survey Provider Enhanced Report, and the Area Health Resource File, researchers concluded that retention of certified nursing assistants (CNAs) in nursing homes is not simply the absence of turnover. The mean annual turnover rate was found to be 55%; the mean annual facility retention rate was 64%.1

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Commentary by Dr Sabol:

CNAs have long played an important role in providing quality, person-centered care to nursing home residents.

High CNA turnover and/or low retention rates have been linked to lower quality care and lower quality of life for residents. There has been a historic tendency to focus primarily on factors that reduce CNA turnover rates; less is known, however, about factors that improve CNA retention rates.

While turnover and retention rates are often linked, this study suggests that these metrics do not have a perfect reciprocal relationship, and improvement in 1 metric does not automatically equate to improvement in the other metric. For example, to reduce CNA staff turnover, best practice suggests more consistent work assignments (staff to resident pairing) to improve overall job satisfaction.

Consistent work assignments, however, are dependent on a stable workforce (or a high retention rate) from which to draw upon. Hence, understanding the factors that drive both of these metrics is an important step in maintaining a strong and skilled CNA workforce.

Advanced practice nurses (APNs) are well-positioned to lead and build strong, high functioning care delivery teams where CNAs as frontline workers can be visibly recognized and valued by multiple stakeholders.

Such leadership may not only contribute to workplace stability, but also facilitate other team-based factors that reduce staff turnover and/or promote retention, and improve resident outcomes and quality of life.

Appropriate Nurse Staffing Levels or US Nursing Homes

Health Serv Insights. 2020;13:1178632920934785.

Researchers outlined a detailed methodology for determining whether or not nurse staffing in a nursing home is adequate.2 This guideline includes the following 5 steps:

  1. Determine collective resident acuity
  2. Determine facility’s actual per resident per day staffing levels
  3. Determine appropriate nurse staffing levels based on resident activity
  4. Identify evidence regarding the adequacy of staffing
  5. Analyze the adequacy of facility staffing

Commentary by Dr Sabol:

Research has revealed that appropriate levels and mix of nursing staff in US nursing homes can improve quality of care and quality of life outcomes. However, data suggest that most nursing homes do not have adequate nurse staffing levels and, in particular, registered nurses (RNs).

Indeed, the COVID-19 pandemic has highlighted the dangers of low staffing levels. Accordingly, the authors present a 5-step guide to determine whether nurse staffing in a nursing home is both adequate and appropriate per current federal and state requirements.

In addition to attaining/maintaining adequate staffing, it is also important to require ongoing education, training, and evaluation to meet variable and often complex resident healthcare needs.

While APNs may not necessarily be directly involved with staff scheduling or training per se, they would be well-advised to advocate for consistent staffing ratios and competency education/training that adequately meet resident care needs and acuity levels. As noted in the previous study, adequate resources (which includes sufficient and competent staff) are a factor in CNA staff turnover and/or retention rates.

Effects of Registered Nurse Staff on Quality of Care and Resident Outcomes in Nursing Homes

Geriatr Nurs. 2020;41(6):685-691.

In an analysis of RN staffing in South Korean nursing homes, researchers found that the number of RNs at a facility is directly related to patient mortality and quality of care; as the number of RNs increased, so did the care quality.3

Commentary by Dr Sabol:

This study looked at RN staffing levels in nursing homes outside the United States, specifically South Korea. Consistent with studies conducted in the US, having a higher number of RNs is associated with lower resident mortality rates, but not related to the residents’ to other health outcomes (eg, falls, severe pain, pressure injuries/ulcers, urinary tract infections, and physical restraints).

The authors suggest these results are likely due to the ambiguous role of the RN. For example, in the majority of cases, RNs acted as managers rather than direct care providers. 

In addition, current South Korean law states that 1 RN or 1 CNA is required per 25 patients; failure to differentiate roles and qualifications and to include a similar salary structure results in limitation of the RN’s role and likely contributes to high turnover rates.

The authors also highlighted that the present evaluation process for nursing home quality in South Korea focuses primarily on structure and process and not on resident health outcomes. In contrast, quality measures in the US include resident health outcomes, which are all influenced by RN scope of practice.

Improvement of South Korean nursing home resident care outcomes would require a major revision of current policies to include resident health outcomes, which RNs can influence. In the fast-moving world of health care, it is vital that all team members, including RNs, can practice to the full extent of their education and abilities to deliver the most efficient quality care to nursing home residents.


  1. Kennedy KA, Applebaum R, Bowblis JR. Facility-level factors associated with CNA turnover and retention: lessons for the long-term services industryGerontologist. 2020;60(8):1436-1444. doi:10.1093/geront/gnaa098
  2. Harrington C, Dellefield ME, Halifax E, Fleming ML, Bakerjian D. Appropriate nurse staffing levels for U.S. nursing homesHealth Serv Insights. 2020;13:1178632920934785. doi:10.1177/1178632920934785
  3. Cho E, Kim IS, Lee TW, Kim GS, Lee H, Min D. Effects of registered nurse staffing on quality of care and resident outcomes in nursing homesGeriatr Nurs. 2020;41(6):685-691. doi:10.1016/j.gerinurse.2020.04.001