Staff turnover is problematic for the healthcare industry, decreasing unevenly across settings and staff types from pandemic highs.¹ Recent research estimates the average annualized nursing staff turnover in U.S. nursing homes to be 128%.² Patients may suffer from high nursing staff turnover as it is associated with increased likelihood of pressure ulcers, pain, urinary tract infections, and readmissions.³

An important question for regulators and providers is what can be done to reduce the alarmingly high turnover in the industry. One important possibility is that improved leadership practices from facilities’ managers and administrators affect retention and turnover.⁴ Using data from the Nursing Home Culture Change 2016–2017 survey, Berridge and colleagues⁴ found that an index of leadership and staff empowerment was associated with high nursing assistant retention (above 76% compared to 0–50%). Another analysis revealed that in nursing homes with lower turnover rates, employees reported better patient safety culture.⁵ This manuscript uses a new source of data to create specific turnover rates for different types of nursing staff at the nursing home level.

The Long-Term Care Facility Staffing Payroll-Based Journal (PBJ) system collected by CMS relies on payroll data to track turnover in nursing homes.⁶ This relatively new data source, begun in 2016, helps to illuminate the causes and consequences of turnover in nursing homes.¹ The quality of turnover data from a payroll-based system may be higher and more precise than turnover estimated by leadership.^{1, 6}

This study examines the relationship between a facility’s leadership’s commitment to workers’ safety, health, and wellbeing and the turnover of its nursing staff using a new measure of leadership in the work environment. This measure is distinct from previous measures of leadership in that it focuses solely on worker safety, health, and wellbeing leadership. and We build on a growing literature analyzing the linkages between leadership and staff retention. Notably, while this literature often relies on self-reported turnover, we leverage administrative payroll data to precisely measure facility-level turnover.

There were 569 responses to the survey across the three states. 46 nursing homes were excluded from the analysis because they were missing 2018Q1/2018Q2 staffing measures. An additional four were excluded because they did not have sufficient data in the PBJ to calculate turnover rates. Another 19 were missing at least one question of the WISH Leadership Domain and were omitted. Finally, nine nursing homes were removed because their payroll data indicated they were outliers. As a result, there were 495 nursing homes in the analysis sample. Excluding nursing homes that were outliers, there was no statistically significant difference in the average turnover rates for nursing homes included versus excluded in the final sample. The distributions of the turnover variable for each nursing type and the WISH Leadership Score are given in Figure 1.

The unadjusted turnover rate was lower for those nursing homes that scored higher on Leadership Commitment to worker safety, health, and wellbeing (Figure 2). Coefficients from the OLS regression were transformed into percent changes by multiplying by 100. The difference was greater for RNs, but still important for LPNs and CNAs. After controlling for additional variables, greater leadership commitment was still associated with lower turnover but with slight attenuation (Figure 2).

Nursing homes with leadership that communicated and demonstrated commitment to worker safety, health, and wellbeing had relatively fewer nurses leave during the study period, with turnover rates about 10% lower than homes without. The result that better leadership was associated with lower turnover fits with the overall idea that workplaces using “best practices” for worker safety, health, and wellbeing may have better organizational outcomes. Nursing homes with leadership that communicated and demonstrated commitment to worker safety, health, and wellbeing had relatively fewer nurses leave during the study period. This finding mirrors the results from Berridge and colleagues but includes additional types of nursing staff and gives more precise differences in turnover rates.⁴

The leadership domain of the Workplace Integrated Safety and Health Assessment is defined as “[l]eadership makes worker safety, health, and well-being a clear priority for the entire organization. They drive accountability and provide the necessary resources and environment to create positive working conditions.” It measures leadership best practices for an integrated approach to protect and promote worker safety, health, and wellbeing.⁸ Leadership has been shown to affect many work-related safety, health, and wellbeing outcomes.^{11, 12} Specifically, it has been associated with job-related well-being, safety climate, and work-related injuries.^13–16 For example, there is a complex relationship between work-related injuries and turnover, but some authors have found that injuries increase the risk of termination (voluntary or involuntary) among healthcare workers.^{17, 18} Leadership may improve working conditions by implementing policies and programs that promote and protect worker safety and health (item b). Additionally, leadership as measured here (items a, c, and d) may influence job satisfaction and engagement—both of which may be related to turnover. Future research, particularly qualitative research, will be essential to illuminating the exact mechanisms by which leadership may influence turnover.

Fortunately, there is existing work that highlights the malleability of leadership, including validated curriculum to protect and promote worker health.^19–21 The STAR (Support.Transform.Achieve.Results.) process was designed to create a work culture that supports and promotes workers’ health and well-being.²² Previous work has shown that this intervention reduced work-family conflict. There are several other interventions to improve leadership as well, some with a focus on safety and health promoting leadership.^19–22

As with all research, ours is subject to several limitations. Our survey covered only three states, California, Massachusetts, and Ohio, so we cannot extend the results to other states that have different competitive and policy environments. The survey also only covered nursing homes with at least 30 beds, so we are unable to make any assessments about smaller nursing homes, which may have very different working environments. While we did not find any differences in observable characteristics between the respondents and non-respondents, we cannot rule out differences based on unobservable attributes. We controlled for county-level nursing home turnover but were not able to control for turnover in the broader labor market for nurses that would include other types of healthcare facilities, such as hospitals and offices. Additionally, we could not control directly for resources outside of those dedicated to protect and promote worker health that were included in the measure of leadership.

These findings suggest that leadership may be a valuable tool for reducing staff turnover. Therefore, regulators and providers concerned about high staff turnover in the industry might look to improving the commitment of nursing home leadership to their staff as means by which to achieve improvement. Further research into the causes of turnover should include measures of the workplace health and safety environment in addition to the labor market. Additionally, this dimension of leadership may be a useful tool to reduce turnover in other areas of healthcare.