Research Findings: The Impact of Healthcare Worker Turnover on Quality of Care

In the research described below, we see trends that we all intuitively and anecdotally know to be true.  Turnover leads to more turnover, leads to a cycle of increasingly exhausted and overworked nurses and staff.  When nurses have to compensate for vacancies and are challenged by continual churn among fellow nurses and frontline staff, they find themselves unable to give the attention and time to patients that they know are needed.  

As conditions like these persist, we can observe and measure the impact:

  • Worker frustration, exhaustion, and burn-out
  • Increased turnover – leaves and quits 
  • Compromised quality of care 
  • Patient and family dissatisfaction 
  • Escalating costs related to all of the above  

The traditional method of measuring the cost of turnover at an acute care facility or long-term care community, has focused on the cost of talent acquisition (recruiting, identifying, evaluating). Some methods of measuring the costs of turnover also take into account the full costs of training and onboarding a new hire. This includes the amounts paid to the new employee during training, to the individuals who train the new employee, and also the cost for the workers who are required to cover for both the workers who provide training and the not-yet-up-to-speed new employee.

As the research below reveals, the cost of turnover among healthcare workers is, in fact, much higher than these finite expenses. The impact of turnover is felt across a unit, department, and community.

If not managed and stabilized, turnover leads to a spiral of increasing turnover, making it very difficult for organizations to deliver on their mission of providing quality care and service to acute-care patients, long-term care residents, and their families.

While a vacancy exists, a healthcare provider must hire a temporary replacement or request that current staff fill in as needed. Often, staff feel overburdened during this time. They may be overworked due to short-staffed units and shifts. They may be overworked by virtue of taking on over-time and longer shifts. They may be unhappy and overburdened by the struggle to complete their own work while supporting a temporary new-to-the-team contract laborer. 

The burdens on current staff do not ease immediately after a replacement hire is made. Varying lengths of time are needed for onboarding and training.

The timeframe for the impact of turnover, however, is not merely the time between an employee’s departure date and the date upon which a replacement hire completes all training.

Prior to leaving or being terminated, a disengaged employee is not likely to be providing the highest level of care or service. The impact of this time period is felt by staff, patients, residents, and families.

A significant body of research attests to this connection between a dissatisfied or disengaged caregiver and the quality of care. Researchers have reviewed a range of data – from medical errors to falls to patient satisfaction surveys – and consistently found correlations to overworked or disengaged staff.

Research Summaries

Data collected from 268 nursing units at over 100 hospitals found that instability in the nursing workforce implies adverse impacts on the continuity and quality of patient care.” They found that low levels of turnover were associated with fewer patient falls and fewer medication errors. The authors recommended that nursing unit turnover be managed within appropriate levels as a critical step in delivering high‐quality patient care. 1Bae, S., Mark, B., & Fried, B. (2010). Impact of Nursing Unit Turnover on Patient Outcomes in Hospitals. Journal of Nursing Scholarship, 42(1), 40–49. https://doi.org/10.1111/j.1547-5069.2009.01319.x

An analysis of 23 nursing units (ICU and medical/surgical) found that nurse manager turnover negatively affects patient outcomes. Compared to units who experienced no management turnover, those with turnover had over 3 times the odds of having one or more patient pressure ulcers occur in the unit in any given quarter. 2Warshawsky, N., Rayens, MK., Stefaniak, K., Rahuman, R. (2013). The effect of nurse manager turnover on patient fall and pressure ulcer rates. Journal of Nursing Management, 21 (5), 725-732. https://doi.org/10.1111/jonm.12101 

Primary data collected from a sample of 2,840 nursing homes found that, across all quality measures, an increase in NA (nursing assistant) agency staff is associated with an increase in quality of care concerns. Increased DON (Director of Nursing) turnover is associated with a decrease in RN (registered nurse) staffing levels and an increase in the use of NA (nurse assistant) agency staff.3Castle, N., Lin, M. (2010). Top management turnover and quality in nursing homes. Healthcare Management Review, 35(2), 161-174. https://doi.org/10.1097/HMR.0b013e3181c22bcb 

A study of clinicians at community mental health centers in Indiana and Missouri examined the relationship between over-time work and perceptions related to quality of care. Results showed that participants who reported working overtime experienced significantly more burnout on all 3 indices: greater emotional exhaustion, depersonalization, and significantly lower personal accomplishment. Even working a few extra hours per week may be a risk factor for burnout as well as negative for perceptions of work-life balance, job satisfaction, and quality of care.4Luther, L, Fukui, S., Rollins, A., Gearhart, T., Morse, G., Salyers, M. (2017). Working overtime in community mental health: Associations with clinical burnout and perceived quality of care. Psychiatric Rehabilitation Journal, 40(2), 252-259. http://dx.doi.org/10.1037/prj0000234 

In a study of 110 Army treatment facilities (hospitals and clinics) across 35 health care systems, aggregated nurse satisfaction was the most consistent predictor of both patient satisfaction and adverse events.5Perry, S., Richter, J., & Beauvais, B. (2018). The Effects of Nursing Satisfaction and Turnover Cognitions on Patient Attitudes and Outcomes: A Three‐Level Multisource Study. Health Services Research, 53(6), 4943–4969. https://doi.org/10.1111/1475-6773.12997

Employee satisfaction data obtained from 146 Veterans Affairs Medical Centers (VAMC) also found that higher employee satisfaction with the organization is associated with improved patient safety and higher patient satisfaction.  In health care, employee job-specific satisfaction and satisfaction with the organization are distinct metrics. Job-specific satisfaction doesn’t correlate with patient outcomes, but organization-specific satisfaction does.6Kang, R., Kunkel, S., Columbo, J., Goodney, P., & Wong, S. (2019). Association of Hospital Employee Satisfaction with Patient Safety and Satisfaction within Veterans Affairs Medical Centers. The American Journal of Medicine, 132(4), 530–534.e1. https://doi.org/10.1016/j.amjmed.2018.11.031

In one of the largest studies on this topic, similar correlations were found. Data included survey results from over 95,000 registered nurses taking the Multi-State Nursing Care and Patient Safety survey, and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which is a national, standardized, publicly available database of patients’ hospital experiences in short-term, acute care hospitals.  High levels of burnout and job dissatisfaction among hospital nurses were associated with lower patient satisfaction, which signals problems with quality of care.7Mchugh, M., Kutney-Lee, A., Cimiotti, J., Sloane, D., & Aiken, L. (2011). Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs (Project Hope), 30(2), 202–210. https://doi.org/10.1377/hlthaff.2010.0100

In a study on the impact of different nurse staffing strategies at 311 California hospitals, researchers found that the increased use of contract RNs in hospitals has a large and statistically significant negative impact on patient satisfactionThe share of contract RN hours in a hospital was a significant predictor of low patient satisfaction. Overall, findings indicate that the frontline staffing level and proportion of core RNs to contract RNs are important factors driving patient satisfaction.8Hockenberry, J.M., Becker, E.R. (2016). How do hospital nurse staffing strategies affect patient satisfaction? ILR Review, 69(4), 890-910. https://doi.org/10.1177/0019793916642760  

Similar studies across the world show that the United States is not alone in this correlation. A study of 104 German Hospitals, for example, found that patient satisfaction with regard to nursing care is significantly negatively related to all direct shortage measures — nurse shortage, nurse vacancies, and nurse turnover.9Winter, V., Schreyogg, J., Thiel, A. (2020). Hospital staff shortages: Environmental and organizational determinants and implications for patient satisfaction. Health Policy, 124(4), 380-388.https://doi.org/10.1016/j.healthpol.2020.01.001 

How to break the cycle of worker turnover

Many factors contribute to worker turnover, and an in-depth examination of possible contributing factors should take place if over 27% of new hires are leaving within 6 months. Keeping compensation and benefits current, offering flexibility in scheduling, and ensuring that worker feedback is anonymously collected and responded to on a regular basis are essential first steps.

Then, if an organization has been aware of and working on preventing the conditions that cause burn-out and fatigue — and most healthcare organizations have been doing this for over a decade — it must make changes at the source. It is time to invest in a data-informed, bias-free process of optimizing the hiring of people who will work well within existing teams and remain committed to the organization’s mission. Arena’s predictive analytics technology is often leveraged for these purposes. To learn more about how AI can impact turnover in this way, the stories of several hospitals, senior living providers, and skilled nursing facilities are described here.

References   [ + ]

1.Bae, S., Mark, B., & Fried, B. (2010). Impact of Nursing Unit Turnover on Patient Outcomes in Hospitals. Journal of Nursing Scholarship, 42(1), 40–49. https://doi.org/10.1111/j.1547-5069.2009.01319.x
2.Warshawsky, N., Rayens, MK., Stefaniak, K., Rahuman, R. (2013). The effect of nurse manager turnover on patient fall and pressure ulcer rates. Journal of Nursing Management, 21 (5), 725-732. https://doi.org/10.1111/jonm.12101 
3.Castle, N., Lin, M. (2010). Top management turnover and quality in nursing homes. Healthcare Management Review, 35(2), 161-174. https://doi.org/10.1097/HMR.0b013e3181c22bcb 
4.Luther, L, Fukui, S., Rollins, A., Gearhart, T., Morse, G., Salyers, M. (2017). Working overtime in community mental health: Associations with clinical burnout and perceived quality of care. Psychiatric Rehabilitation Journal, 40(2), 252-259. http://dx.doi.org/10.1037/prj0000234 
5.Perry, S., Richter, J., & Beauvais, B. (2018). The Effects of Nursing Satisfaction and Turnover Cognitions on Patient Attitudes and Outcomes: A Three‐Level Multisource Study. Health Services Research, 53(6), 4943–4969. https://doi.org/10.1111/1475-6773.12997
6.Kang, R., Kunkel, S., Columbo, J., Goodney, P., & Wong, S. (2019). Association of Hospital Employee Satisfaction with Patient Safety and Satisfaction within Veterans Affairs Medical Centers. The American Journal of Medicine, 132(4), 530–534.e1. https://doi.org/10.1016/j.amjmed.2018.11.031
7.Mchugh, M., Kutney-Lee, A., Cimiotti, J., Sloane, D., & Aiken, L. (2011). Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs (Project Hope), 30(2), 202–210. https://doi.org/10.1377/hlthaff.2010.0100
8.Hockenberry, J.M., Becker, E.R. (2016). How do hospital nurse staffing strategies affect patient satisfaction? ILR Review, 69(4), 890-910. https://doi.org/10.1177/0019793916642760  
9.Winter, V., Schreyogg, J., Thiel, A. (2020). Hospital staff shortages: Environmental and organizational determinants and implications for patient satisfaction. Health Policy, 124(4), 380-388.https://doi.org/10.1016/j.healthpol.2020.01.001