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Workforce Retention in LTC
Overview | CNA |
Nurses | Administrator
| Quality Improvement | Related Tags
| Additional Resources |
Bibliography | Reviewers |
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This is a resource page rather than a completed best practice framework.
Overview
The DADS Quality Assurance and Improvement vision for Workforce Retention in LTC is that
Every LTC facility will have a stable, well-trained staff.
Definitions of Caregiver Turnover
The LTC literature reveals no consensus definition of caregiver turnover, beyond distinguishing between voluntary and involuntary turnover.[1] Annual turnover rates may be calculated by dividing the difference between the number of indivuals (RNs, LPNs, or CNAs) employed during the fiscal year and the number employed at the end of the year by the number employed at the end of the year, which multiplied by 100 produces a rate.[2] An alternative conceptualization is the number of employee terminations divided by the total number of worker positions. Annual turnover rates do not always yield an accurate picture of staff retention since nurses and CNAs often leave during the first 180 days of employment.[3,4,5] Thus, frequent changes in a few positions may create the appearance of a relatively inexperienced workforce when, in fact, only the staff in those few high-turnover positions are inexperienced and the remainder consists of veterans.
Maintaining quality staff, in the face of increasing demand for LTC workers presents a formidable challenge.[4] Excessive turnover affects continuity of care, quality of care, and the cost of care. Turnover costs include the costs of hiring and training new staff as well as costs incurred from diminished productivity.[4,5,6] Recruiting and training a new CNA may cost $4,000.[7]
Staff Turnover Rates
Recent surveys have found that CNAs turnover generally ranges from 49% to 400%. [4,5,6,7,8] The national average of 71% is significantly lower than the 179% reported by a 1996 survey in Texas. [4,9] A 2001 survey found the turnover rate for RNs was 56%; for LPNs the rate was 43%. In 2002, the turnover rate for nursing home DONs was 50%, up more than 3% since 2001. [10] Among nursing home administrators, turnover rates range from 20% to 50%.[11,12]
The conceptual model shown below provides a high-level view of how certain factors can influence employee satisfaction and thus alter retention.
Turnover and Retention of Nursing Assistants
An understanding of intrinsic factors associated with turnover and retention can inform recruiting and hiring practices. A number of extrinsic factors associated with turnover and retention have been identified, and while many appear intuitively correct, the available literature is inadequate to confirm their utility as predictors. In this framework, extrinsic factors associated with turnover and retention are designated as either "supported by evidence" or "anecdotal report" based on the presence and quality of supporting evidence.
Intrinsic Factors Associated with Turnover and
Retention
- Age - younger workers are less likely to remain on the job; workers over age 30 are more likely to stay [13,14]
- Education - workers with more than a high school education are more likely to turnover as are those less intent on educational advancement [13,14,16]
- Lack of job preparation - inadequate skills, or job training without sufficient emphasis on hands-on skills is linked to turnover [15]
- Marital status and dependent children - workers for whom employment is the sole source of income for themselves and dependents are more likely to remain on the job [13,14]
- Adequate social support - workers with reliable childcare and transportation are more likely to remain on the job [14]
- Employment tenure - shorter prior job tenure may be associated with turnover [13]
- Attitudes and values - workers oriented toward extrinsic rewards such as salary and benefits are less likely to stay while "people-oriented," workers who value being needed and part of a group, are motivated by intrinsic rewards, demonstrate a positive affect toward older adults, feel a sense of control in their work environments, and view working with older adults as their occupation of choice are more likely to stay [13,14,15,16,17,18]
- LTC workers with strong interpersonal skills from other departments (e.g., housekeeping and food services) who are trained to become CNAs are more likely to stay [19]
Extrinsic Factors Associated with Turnover
Supported by evidence
- Multiple opportunities for employment in local job market [14,18]
- Inadequate job orientation and training [6,13,14]
- High RN turnover [2]
- Investor-owned and for-profit LTC facilities and facilities that serve as training sites [4,20]
- Payer mix - higher proportions of residents with Medicaid [4,20]
- Working conditions - at or in excess of federally mandated workload, as defined by staff-to-patient ratios [6,7,13]
- Changing resident assignments - disrupting continuity of care and bonds between residents and caregivers [13,17]
- Lack of respect [6,7,13,15, 16,17,18]
- Wages and benefits [6,7,13,15,17,20]
Anecdotal reports
- Incongruity between nursing home goals and the bureaucratic structure with top-down control used to achieve them [14,15]
- Organizational climate that emphasizes merit-based rewards [2]
- Job is both high-demand and highly routine [14]
- Limited career opportunities [13]
- Poor supervision and poor communication between management and NAs [13,15,18]
- Insufficient involvement in management decision making and quality improvement initiatives [13]
- Perceived inequities that result in dissatisfaction [14]
- Lack of control and autonomy [17]
- Stigma associated with the perception that work lacks prestige, is unskilled, and "dirty" [18]
- Racism, classism, ethnocentrism [18]
Extrinsic Factors Associated with Retention
Supported by evidence
- Clean, safe, well-supplied work environments [16]
- Smaller facilities; those with formal relationships with hospitals; and those with no recent ownership change [4]
- Relatively fewer LTC beds in the county - lower market concentration creates competition for workers, which in turn increases wages [4]
- Payer mix - less reliant on Medicaid funding [4]
- Higher staffing ratios [2,7,13,16]
- Workers covered by union contract [2,4]
- Low rates of professional staff (RN) turnover [1,4]
- Positive relationships with residents, supervisors and coworkers [13,14,16,17,21]
- Employee recognition [13,16,17,19,21]
Anecdotal reports
- Recruit personnel whose goals can be met by the organization; careful hiring, orientation and mentoring [15,16]
- Promote a higher organizational purpose and lead with inspiring values [22]
- Open, flexible organizational structures with shared participation in decision making; involve nursing assistants in resident care planning and work-related decisions; job design emphasizes total patient care as opposed to task-related care [4,13,14,15,22]
- Demonstrate interest in personal growth - create opportunities to learn new job and life skills [22]
- Family-oriented facility and sense of community- (e.g., welcoming employees' children when schools are unexpectedly closed for weather, facilitate social interactions with employees to get to know their interests and values) [22,23]
- Provide supportive services such as assistance obtaining childcare and transportation [22,24]
- Presence of trainer to advocate for and administer professional development, recognition, mentoring and other retention programs [8]
- Perceived organizational support from top management [8,14]
- Primary care relationships between workers and residents to establish enduring bonds [23]
- Professional growth and job enrichment opportunities [13,16]
- Keep employees well informed and build trust via open, timely and accurate communication [2,13,22]
- A career ladder - opportunities for development and advancement; compensation tied to professional development; salary increases based on participation in career ladder and mentoring programs [8,15,19]
- Onsite in-service education to improve capacity to care for residents as opposed to career advancement [16]
- Supervisory training for nurses supervising NAs [13,14]
Recruitment and Retention of Nursing Personnel
Recruiting and Retaining Geriatric Nurse Practitioners (GNPs) [26]
Intrinsic factors that attract GNPs to LTC
- Positive experiences with older adults
- Education, preparation or past professional experiences
Extrinsic factors that attract GNPs to LTC
- Care versus cure orientation
- Position of authority
- Role model or mentor
- Flexible hours
- Salary
- Adequate staffing
Factors associated with GNP job satisfaction
- Appreciation from families and patients
- Primary care responsibility
- Hours
- Authority
- Recognition
- Staff camaraderie
- Salary and benefits
- Professional opportunities
- Pleasant environment
- Educational opportunities
Deterrents to Attracting Clinically Competent Nurses to LTC [26]
Individual factors
- Peers hold negative image
- Negative public image of LTC [18,26]
- Lack of geriatric expertise
- Lack of interest in older adults
- Negative educational experiences
Organizational Constraints
- Lack of appropriate staffing, equipment, professional support and challenge
- Wages and benefits
Intrinsic Factors
- Age, education, marital status, number of dependents supported - younger nurses, those with more education, and those who do not provide sole support for dependents are more likely to remain on the job; younger and better-educated DONs are more likely to leave [2,4,10]
- Inadequate training and preparation of DONs, especially in nonclinical, administrative aspects of the job (e.g., managing state inspections, liability, budgets, HR issues and continuous quality improvement (CQI) monitoring systems) [10]
- Feeling overextended or incompetent [13]
- Unable to adapt to LTC [25]
- Feeling a sense of belonging in LTC and a member of a healthcare team is associated with retention [17]
- Satisfaction with identity/role as nurse-leader [10]
- Satisfaction derived from relationships - with residents, staff members, families and colleagues [10]
Extrinsic Factors Associated with Turnover
Supported by evidence
- Facility size - larger facilities had lower RN turnover rates [2]
- Payer mix - higher proportions of residents with Medicaid [4,20]
- Availability of alternate employment - labor market conditions [4]
- Wages and benefits [4,20]
- Turnover among top management is associated with nursing turnover [1]
Anecdotal reports
- Job stress [4]
- Role clarity and job design [4]
- Excessive administrative and clerical responsibilities - documentation and charting prevent delivery of patient care [18,25]
- Responsibilities such as budgeting, planning, interdepartmental communication, long-range planning, HR functions, documentation, marketing; compliance and risk-management fall outside of the nurse managers' areas of expertise and preferences [10]
- Leadership effectiveness [4,25]
- Career expectations including assuming a nurse-leadership position and ensuring residents' well-being are at odds with expectations of DON role with accountability for human resources (HR) issues, liability, compliance, and reimbursement [10]
- Unreasonable time demands that compromise DONs' personal lives [10]
Extrinsic Factors Associated with Retention
Supported by evidence
- Hire nurse managers with histories of low turnover [1]
- Competitive salaries and benefits [1,25]
- Flexible scheduling [1,25]
- Acuity - low nurse-to-patient ratio [2,25]
- Greater availability of clinical resources - greater LPN hours per resident day related to lower LPN and lower RN turnover [2]
- High levels of job satisfaction (4,18]
- Longer tenure of the DON [2]
Anecdotal reports
- Good work environment [25]
- Teamwork/peer support [25]
- Shared decision making [27]
- Supportive management [25]
- Nursing homes with cultures emphasizing merit-based reward and open, timely and accurate communication (LPNs only) [2]
- Greater availability of clinical resources - greater LPN hours per resident day related to lower LPN and lower RN turnover [2]
- Quality relationships with nurse supervisors is associated with higher levels of organizational trust and commitment [27]
- Congruence between the nurse's professional needs and preferences and the work environment and job [5]
- Professional management development, especially for nurses without advanced degrees who have been promoted into supervisory and management positions and those new to LTC [27,19]
- Executive development programs [1]
- Formal transfer policies [1]
- Encouraging sense of belonging and fit in organization [1]
- Positions emphasizing activities nurse managers enjoy - direct-care and clinical issues, quality improvement, family relations, staff mentoring, and professional development [10]
- Peer-monitoring and mentoring systems [10]
Turnover and Retention of Nursing Home
Administrators
[12]
Intrinsic Factors
Individual ability and willingness to adapt to, and manage, change is associated with retention.
Extrinsic Factors from Anecdotal Reports
The principal extrinsic factors are the nature of the job and the characteristics
of the work setting. The nature of facility administration is constantly
evolving, and the roles and responsibilities of nursing home administrators
have grown increasingly complex in response to:
- Greater reporting and regulatory requirements
- Earlier hospital discharge of acute and subacute patients
- Greater specialization and competition
-
Enactment of the 1987 Nursing Home Reform Act (NHRA) (part of the Omnibus
Reconciliation Act; OBRA) expanded the administrator's responsibilities by
establishing new requirements including monitoring for:
- Quality of care - assessed via survey inspections
- Resident assessment, care planning and case management
- Use of medications and physical restraints
Individual anecdotal reports have noted the trends and relationships listed
below.
- Hospital-based LTC facilities are more likely to experience administrator turnover than freestanding facilities because they generally have a higher acuity population requiring more intensive services.
- Turnover is higher in facilities belonging to a chain, compared to independent facilities. This may reflect the practice of relocating skilled administrators to trouibled facilities in the chain.
- Turnover is higher in government facilities than in nonprofit LTC facilities.
- From the late 1990s, facilities with higher proportions of Medicaid residents experienced higher turnover.
- LTC facilities adopting innovations in service delivery seem to experience more turnover. The cause(s) for this finding are not clear.
- Poor quality of care is associated with higher rates of administrator turnover. The cause(s) for this finding are not clear.
Practical Guide to Quality
Improvement
Part I. Identify Turnover Risks
A poor fit between employee and work environment is associated with low employee satisfaction and increased turnover. Screen prospective employees and measure the overall fit between their personal needs and the organizational culture and work environment.
Part II. Periodically Assess Employee-Environment Fit [5,27]
Use this framework to identifiy the factors that can affect turnover and
retention. Then determine which factors are most important to your staff
and which of those you can influence and control. Use
validated instruments such as those listed below to identify issues that
you can address in order to improve employee satisfaction and staff retention.
- Minnesota Importance Questionnaire - measures employees' work preferences
- Minnesota Job Description Questionnaire - measures environmental characteristics
- Vocational Preference Inventory - measures employees' preferences for occupational activities and their abilities
- Self-Direction Search - measures employees' inclinations for work activities and their capabilities
- Dictionary of Holland Occupational Codes and Position Classification Inventory - provides characteristics of occupations
- Organization Culture Profile (OCP) - measures employees' preferences in organizational culture and cultural-value congruence
- Index of Work Satisfaction (IWS) - measures perceived importance of factors essential to satisfaction and the current level of satisfaction with subscales for pay, autonomy, task requirements, organizational policies, interaction and professional status [27]
- Anticipated Turnover Scale (ATS) - measures workers' perceptions about the possibility of leaving their current job [27]
Part III. Promising Programs
This section outlines a representative sample of programs that have demonstrated the potential to recruit and retain staff; however, because each intervention addresses specific organizational issues in context, there is no single intervention that can be applied uniformly.
Recruit to Yield Higher Retention Rates
- Recruitment efforts emphasize identifying prospective employees that share the organization's values; shared values fosters shared accountability [28,3]
- Staff interviews and orientation conducted by the facility CEO act to immediately establish rapport, camaraderie and a sense of belonging to a community or team of caregivers [19]
Enhance Employee Communication and Participation
Hold formal retention conversations with employees every two to three months.[3] Use these opporuntities to determine the factors that initially attracted the worker to the organization and identify the factors that will sustain and enhance the worker's engagement. Document each worker's responses in a database for use in future retention conversations.
Job Training and Development Interventions
Career development for CNAs
[19]
- Ten 3-hour training units featuring hands-on, interactive learning includes serving on an interdisciplinary team with physicians to coordinate care plans. Graduates receive the title, "Caregiver I."
- Subsequent training immerses CNAs in care planning and units focus on chronic diseases and pain management. Graduates are termed "Caregiver II" and receive a bonus and certificate.
LEAP [21]
The acronym describes the program's objectives:
- Learning to use tools and resources for quality LTC
- Empowering caring and competence in self and others
- Achieving commitment to work teams and the organization
- Producing opportunities for growth and development
The program consists of two modules:
- Module 1 trains nurse managers to develop as leaders, gerontological clinical experts, role models and team builders, and focuses on the relationship between nurses and CNAs
- Module 2 emphasizes skill development, mentorship program for CNAs and a career ladder
Teaching CNAs Complementary Therapies [29]
Five 90-minute teaching sessions covered cognitive techniques and meditation, spirituality, healing touch, yoga, and integration. CNAs were taught how to use these therapies themselves and how to integrate the therapies into daily routines with residents. Availability of this type of professional/personal development may be used in recruiting efforts.
Professional Development
These are programs desgined especially for nurses without advanced degrees who have been promoted into supervisory and management positions.[27] Leadership training emphasizes the differences between leadership and management.[19]
Employee Recognition Programs
In some programs, employees are nominated by one another, volunteers, or residents for performing exemplary service.[19] Other successful programs recognize individual character (e.g. kindness, patience, dedication) rather than service.
Coaching-Style Management [3]
- Hold workers accountable for high performance
- Follow up with clear, honest, accurate and timely feedback
- Use every instance of delivering feedback as an opportunity for coaching
Job-retention program for entry-level employees
[24]
- Pairs social workers with new hires - available onsite and by telephone 24/7
- Trains frontline supervisors of entry-level staff
- Teaches core competency skills - Social workers conduct lunch and learn sessions every other week; rewards attendance at sessions
- Provide supportive services to new hires such as assistance with childcare, transportation, uniforms, starting a GED program and repairing their credit
Peer Mentoring for CNAs [30]
Respected veteran CNAs serve as mentors, modeling exemplary care and helping newly hired CNAs, to learn and thrive by transferring their knowledge, compassion, and caring ethics to the new hires. Mentors work the same shifts as mentees and maintain an active relationship for at least 4 weeks.
Mentors
- Improve orientation processes so they reflect the facility's values
- Reinforce critical skills and behaviors
- Teach the value of caring
- Support new staff members and help them feel valued by the facility
- Assist mentees to fit in with their peers and develop positive friendships
Orientation and Training
Mentors receive 6 hours of training; supervisors attend a one-hour workshop to ensure their support of the program; managers receive training materials about how to administer the program and, program coordinators receive 3 hours of orientation and training. Mentors do not teach clinical skills; instead they focus on imparting methods to manage the workload such that the CNA is able to respond to the collective needs of residents rather than work around a rigid task list.
Compensate mentors with:
- Hourly wage increases during mentoring
- Permanent salary increases
- Honorariums for each training session
- Benefits such as extra vacation days or relief from weekend shifts
Part IV. Promising Strategies that Involve Organizational Change
Participatory Management [28,31]
Participatory management increases employee involvement in organizational planning and decision-making through practices that include collaborative problem-solving, teamwork, reciprocal communication, and feedback from workers most directly involved in an issue. These strategies have been demonstrated to increase the probability that quality improvement will be sustained.
The process involves:
- Enriching managerial skills
- Naming a Change Coordinator to facilitate new initiatives
- Improving relationships among participants by interdisciplinary group (i.e., management, staff, family members, residents) activities to identify and prioritize organizational problems, define problems, analyze causative factors and consider alternative
- Expanding knowledge and skill sets for management, staff and families - Topics range from clinical to communication and conflict resolution skills
Open Organizations [14]
Open organizations are based on social exchange theory and King's dynamic
interacting systems are characterized by:
- Flexible structure of networks
- Goal-oriented, people-centered, caring atmosphere
- Interdependent and teamwork-centered leadership structure
- Decision making through problem solving and participation of involved parties
- Positive expectations instead of external rewards and punishments
- Multi-channeled and respectful communication
- Goal-oriented evaluation of employees
Such organizations:
- Practice leadership as opposed to management
- Perceive the product as human caring
- Support employees to maintain their social roles (e.g., childcare, flexible scheduling, affordable health benefits)
- Value the human capital essential to their success
- Define roles unambiguously -- clearly delineating each employee's contribution to overarching organizational goals
- Capitalize on employee strengths and knowledge rather than forcing them into molds
- Model effective interactions and respectful communication - administrators and managers set the tone
- Apply HR policies equitably but not necessarily uniformly
- Reward and plan incentives for excellent performance
- Institute mechanism to address and correct unacceptable performance
- Develop policies and standards of care collectively, which improves adherence
Functional Model of Elder Care
[32]
- Provide training. The program involves four 4-hour sessions covering geriatric syndromes (incontinence, sleep disorders, nutrition, falls, immobility, and loss of functioning) associated with institutionalization.
- Emphasize keeping residents functional. By providing bathing and bed-making every other day CNAs can spend more time increasing patient activity - ambulating, assisting at mealtime, maintaining skin integrity and promoting continence, sleep and rest.
Person Centered Care (PCC) [7]
PCC allows residents to maintain control over their lives to the extent that
their health permits and is characterized by:
- Philosophical shift from custodial care to supporting residents to lead lives characterized by personal satisfaction
- Respect for each resident's life-long patterns, preferences and individual needs
- Creation of individualized living spaces
- Empowerment of direct service staff as advocates for individual resident
- Creating opportunities for personal growth, development and a sense of contribution for workers and residents
- Facilitating continuing connections to the world at large - through participation in events and activities outside the facility
Related Licensure and Certification
Tags
The following deficiencies may be cited in regard to staffing. Some tags that might be cited as evidence that necessary services were not provided to a resident because of staffing issues are also included. The deficiency list is representative rather than exhaustive.
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| Nursing Facilities |
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| ICFs/MR |
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| Assisted Living |
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Additional Resources (including online
resources)
The resources listed below are provided solely as a convenience to our users. These may include publications from government, professional, for-profit, and non-profit sources. Some of these sources may have financial ties to industry. DHS does not control the content of these resources, and the opinions and recommendations provided there are those of the authors and do not necessarily reflect the position of QAI or DADS.
Online
- Agency for Healthcare Research and Quality
- American College of Health Care Administrators
- U.S. Dept of Health and Human Services, Health Resources & Service Administration, Bureau of Health Professionals
- U.S. Department of Labor, Bureau of Labor Statistics
- U.S. Department of Labor, Occupational Safety and Health Administration
Bibliography
[1] Castle NG. Turnover begets turnover. Gerontologist. 2005 Apr; 45(2):186-195.
[2] Anderson R, Corazzini K, McDaniel R. Complexity science and the dynamics of climate and communication: reducing nursing home turnover. Gerontologist. 2004 Jun; 44(3):378-88.
[3] Martin CA. Turn on the staying power. Nurs Manage. 2004 Mar;35(3):21-26.
[4] Brannon D, Zinn J, Mor V, Davis J. An exploration of job, organizational, and environmental factors associated with high and low nursing assistant turnover. Gerontologist. 2002 April;42(2):159-168;discussion 157-158.
[5] Takase M, Maude P, Manias E. Nurses' job dissatisfaction and turnover intention: methodological myths and an alternative approach. Nurs Health Sci. 2005 Sep;7(3):209-217
[6] Fitzpatrick PG. Turnover of certified nursing assistants: a major problem for long-term care facilities. Hosp Top. 2002 Spring;80(2):21-25.
[7] Flesner MK, Rantz MJ. Mutual empowerment and respect effect on nursing home quality of care. J Nurs Care Qual. 2004 Jul-Sep; 19(3):193-196.
[8] Hoffman R. Lessons learned in creating a successful retention program. Nurs Homes Long Term Care Manage. 2001 Apr;50(4):26-30.
[9] Hegeman CR. Turnover turnaround. Health Prog. 2005 Nov-Dec; 86(6):25-30.
[10] Tellis-Nayak V. Who will care for the caregivers? Health Prog. 2005 Nov-Dec;86(6):37-43.
[11] Anderson R, Corazzini K, McDaniel R. Complexity science and the dynamics of climate and communication: reducing nursing home turnover. Gerontologist. 2004 Jun; 44(3):378-88.
[12] Angelelli J, Gifford D, Shah A, Mor V. External threats and nursing home administrator turnover. Health Care Manage Rev. 2001;26(3):52-62.
[13] Parsons SK, Simmons WP, Penn K, Furlough M. Determinants of satisfaction and turnover among nursing assistants. The results of a statewide survey. J Gerontol Nurs. 2003 Mar;29(3):51-58.
[14] Riggs CJ. A model of staff support to improve retention in long-term care. Nurs Adm Q. 2001 Winter;25(2):43-54.
[15] Lescoe-Long M. Why they leave: A new approach to staff retention. Nurs Homes Long Term Care Manage. 2000 Oct;49(10):70-75.
[16] Pennington K, Scott J, Magilvy K. The role of certified nursing assistants in nursing homes. J Nurs Adm. 2003 Nov;33(11):578-584.
[17] Secrest J, Iorio DH, Martz W. The meaning of work for nursing assistants who stay in long-term care. J Clin Nurs. 2005 Sep;14(8B):90-97.
[18] Jervis LL. Working in and around the 'chain of command': power relations among nursing staff in an urban nursing home. Nurs Inq. 2002 Mar;9(1):12-23.
[19] Anders KT. How do you bait the hook? Creative strategies for employee retention. Contemp Longterm Care. 2001; 24(3):24-28.
[20] Harrington C, Swan J. Nursing home staffing, turnover, and case mix. Med Care Res Rev. 2003 Sep; 60(3):366-392; discussion 393-399.
[21] Hollinger-Smith L. It takes a village to retain quality nursing staff. Nurs Homes Long Term Care Manage. 2003 May;52(5):52-54.
[22] Izzo J. Finders keepers. Six secrets to attracting and retaining great employees. Contemp Longterm Care. 2002 Oct;25(10):42-44.
[23] Rudolph G. How you gonna keep'em down on the farm? Make the farm integral to their lives, that's how! Contemp Longterm Care. 2001 Jan;43-44.
[24] Zinn L. Tackling staff turnover: A novel approach. Nurs Homes Long Term Care Manage. 2004 Mar;53(3):50, 52-54, 56-57.
[25] Thompson TP, Brown HN. Turnover of licensed nurses in skilled nursing facilities. Nurs Econ. 2002 Mar-Apr;20(2):66-69, 82.
[26] Karlin NJ, Schneider K, Pepper S. Issues of attraction, retention, and affective states for geriatric nurse practitioners in long-term care. Geriatr Nurs. 2002 Nov-Dec;23(6):324-329.
[27] Wilson AA. Impact of management development on nurse retention. Nurs Adm Q. 2005 Apr-Jun;29(2):137-145.
[28] Deutschman M. Interventions to nurture excellence in the nursing home culture. J Gerontol Nurs. 2001 Aug;27(8):37-43.
[29] D'Eramo AL, Papp KK, Rose JH. A program on complementary therapies for long-term care nursing assistants. Geriatr Nurs. 2001 Jul-Aug;22(4):201-207.
[30] Hegeman CR. Turnover turnaround. Health Prog. 2005 Nov-Dec; 86(6):25-30.
[31] Beck C, et al. Sustaining a best-care practice in a nursing home. J Healthc Qual. 2005 Jul-Aug; 27(4):5-16
[32] Weitzel T, Robinson SB, Henderson L, Anderson K. Satisfaction and retention of CNAs working within a functional model of elder care. Holist Nurs Pract. 2004 Nov-Dec;18(6):309-312.
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Last updated: March 31, 2006