Most of the empirical research examining the relationship between turnover and quality has been conducted in the nursing home setting.



High turnover rates of certified nursing assistants have been associated with poorer quality care for nursing home residents (Bostick, Rantz, Flesner, & Riggs, 2006; Castle et al., 2006; Castle & Engberg, 2005; Mittal, Rosen, & Leana, 2009). Bostick and colleagues found that higher worker turnover rates in nursing homes were correlated with greater use of physical restraints, catheters, and psychoactive drugs, more contractures, pressure ulcers, and quality of care deficiencies. Barry, Brannon, and Mor (2005) found that nursing homes with low turnover and high retention rates experienced lower pressure ulcer incidence rates relative to nursing homes with high turnover and high retention rates. While there are no published studies examining the effects of HHA [Home Health Aide] turnover or other workforce quality measures on client quality of care, studies have highlighted the important role that a positive relationship between the client and the aides plays in quality of life outcomes (Eustis, Kane, & Fisher, 1993; Rodat, 2010).[1]

Most of the empirical research in the literature review examining job satisfaction and turnover intentions/turnover comes from nursing home studies with few that have looked at direct care workers across settings and fewer specifically examining the home care environment. While other factors also play a role, job satisfaction has been found to be a predictor of direct care workers’ intent to leave the job across long-term care settings (Sherman et al., 2008; Matthias & Benjamin, 2005; Decker, Harris-Kojetin, & Bercovitz, 2009; Castle, Degenholtz, & Rosen, 2006; Rosen, Stiehl, Mittal, & Leanna, 2011; Kiyak, Namaze, & Kahana, 1997; Castle, Engberg, Anderson, & Men, 2007). High turnover can have negative consequences for consumers and their families, employers, and policymakers. Workers who remain on the job may be more rushed because they are “working short” and, therefore, provide inadequate or unsafe care (Jobs with a Future Partnership, 2003; Dawson & Surpin, 2001). In addition, turnover and reduced availability of direct care staff make it difficult to provide continuity of care to clients. This lack of continuity disrupts the relationship building between the client and aides, an important contributor to quality of life for disabled individuals. It also limits the time for aides to understand clients’ needs and preferences (Wiener, Squillace, Anderson, & Khatutsky, 2009; Dawson & Surpin, 2001; Jobs with a Future Partnership, 2003; Butler, Wardamasky, & Brennan-Ing, 2012). Aides may be unable to adequately meet the needs of clients, resulting in poor nutrition, discomfort, secondary health conditions, and increased isolation (Kaye, Chapman, Newcomer, & Harrington, 2006). Clients may be turned away and denied access to care because there is not enough staff to meet the demand (Dawson & Surpin, 2001; Jobs with a Future Partnership, 2003). Worker shortages ultimately limit successful public policy implementation, as Medicare attempts to lower costs through the use of post-acute home health care and state Medicaid programs expand home and community-based services and attempt to integrate acute, primary, and long-term services and support for the dual-eligible population (those eligible for Medicare and Medicaid).[2]

Workplace Characteristics: The direct care worker’s assessment of the quality of the relationship between the supervisor and the aide as well as having supportive leadership have been shown over a large number of studies to be a strong indicator of job satisfaction in nursing home and home care settings (Karantzas et al., 2012; Gerstner & Day, 1997; Decker et al., 2009; Beulow, Winburn, & Hutcherson, 1999; Bishop et al., 2008; McGilton, Hall, Wodchis, & Petroz, 2007; DeLoach & Monroe, 2004; Castle et al., 2006; Dawson, 2007; Parson et al., 2003; Karshe et al., 2005; Bishop, Squillace, Meagher, Anderson, & Wiener, 2009). Research also supports that the perceived quality of the supervisor influences an aide’s intention to stay or leave the job, with aides who have a more positive relationship less likely to intend to leave or actually leave the job (Karantzas et al., 2012; Eisenberger, Stinglhamber, Vandenberghe, Sucharski, & Rhoads, 2002; Bowers, Esmond, & Jacobson, 2003; Stearns & D’Arcy, 2008; Brannon et al., 2007; Choi & Johantgen, 2012; Banazak-Holl & Hines, 1996; Bishop et al., 2008; Mittal et al., 2009; Parson et al., 2003; Barborotta, 2010; Straker et al., 2014). Dill et al. (2012) found the opposite–that nursing assistants who reported a higher degree of supervisor support were less likely to intend to stay on their job.[3]


These personnel are considered the “hands, voice and face” of long-term care, responsible for helping frail and disabled older adults carry out the most basic activities of daily life. The majority work in nursing homes and assisted living facilities; however, increasing numbers provide in-home supportive and health-related services. Estimating the size of the home care workforce is particularly difficult—many are missed in surveys because they are directly employed by consumers and/or their families. A recent study suggested their numbers are significantly undercounted (Montgomery, Holley, Deichert and Kosloski, 2006). According to 2006 BLS data, [Bureau of Labor Statistics] the total paraprofessional direct care workforce in both the health and long-term care sectors consists of:

■ 1,391,430 nurse aides, orderlies and attendants, largely employed in nursing homes;

■ 663,280 home health aides, a slight majority of whom work in home-based care settings; and

■ 566,860 personal care and home care aides, two-thirds of whom work in home-based services. The majority of these direct care workers are employed in long-term care settings.[4]

Poor Working Conditions: As is often true in the larger health care sector, the long-term care industry tends to follow an almost military, hierarchal approach to workplace organization and management. Mentoring, coaching, the use of teams and collective involvement of staff in decision making is the exception rather than the rule. Both nurses and aides complain about managers who lack respect for the knowledge and skills they bring to the job and refuse to share information, as well as poor supervision and a feeling that they are powerless to change their work environment (Bowers et al, 2003; Kimball and O’Neil, 2002). The retention of long-term care personnel will not be accomplished without significant changes in human resource practices and systems.[5]

Inadequate/Misplaced Investments in Long-Term Care Workforce Education and Training:

The professional long-term care workforce is not trained to address the special health and medical care needs of elderly consumers. Nationwide, there are few nurses or physicians trained in geriatrics. Nursing home administrators—the chief executive officer in nursing homes— only may need to have a high school diploma and pass an exam. Training requirements governing administrators in other settings such as assisted living or home health range from rigorous to minimal. (Miller and Mor, 2006). Nursing schools, community colleges and technical schools typically do not cover long-term care nursing in more than a cursory way in their curriculum. Anecdotal evidence suggests they may discourage nursing students from even considering long-term care careers. Nursing schools largely fail to prepare RNs to carry out administrative roles—although that is a primary responsibility in longterm [sic] care nursing. They do not adequately prepare RNs or LPNs in effective supervisory approaches, although one of their principal responsibilities is to supervise paraprofessional staff. Nurses also are trained poorly to understand the workforce implications of a culturally diverse paraprofessional workforce or the growing ethnic and racial diversity of older adults who are the consumers of longterm [sic] care. To become certified as nursing assistants or home health aides, individuals are required to have less than two weeks of training. Home care aides are not subject to any federal requirements, and few states require training. Most direct care paraprofessionals appear to learn what is expected of them and how to do their jobs after they have been hired. As a result, large numbers are unprepared for the demands placed upon them and leave their jobs within the first few months. Continuing education requirements for both professional and paraprofessional personnel are minimal. They are typically perceived as book learning without any real link to the reality of the tasks they must perform on a daily basis. There are few rewards for keeping up with the latest information on evidence-based practices or the availability of new technologies. Raising education requirements also could have an undesirable effect if it discourages or delays prospective personnel from entering long-term care jobs; however, improving training may be the only path to creating higher-quality jobs that are more competitive in the labor market.[6]


Strengthen Long-Term Care Nurse Competencies in Geriatrics, Administration, Management and Supervision: Directors of nursing and other nurses employed as administrators and supervisors in long-term care settings need incentives to develop competencies in geriatrics, administration, management and supervision. Long-term care providers could join together to identify nurses and paraprofessional staff with strong leadership potential and develop this potential. Schools of nursing should significantly increase the level of training and education in geriatrics for all nursing students, increase the availability of clinical preceptorships in long-term care settings and offer preparation in frontline [sic] leadership and supervision essential to the effectiveness of the longterm [sic] care nurse.[7]


[1] https://aspe.hhs.gov/report/predictors-job-satisfaction-and-intent-leave-among-home-health-workers-analysis-national-home-health-aide-survey
[2] https://aspe.hhs.gov/report/predictors-job-satisfaction-and-intent-leave-among-home-health-workers-analysis-national-home-health-aide-survey
[3] https://aspe.hhs.gov/report/predictors-job-satisfaction-and-intent-leave-among-home-health-workers-analysis-national-home-health-aide-survey
[6] http://www.leadingage.org/sites/default/files/LTC_Workforce_Commission_Report_0.pdf
[7]  https://aspe.hhs.gov/report/predictors-job-satisfaction-and-intent-leave-among-home-health-workers-analysis-national-home-health-aide-survey



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