Turnover in Nursing Homes that Serve Residents with Serious Mental Illness

Abstract

Objectives: To examine whether nursing facility proportion of residents with serious mental illness (SMI) is associated with nursing staff turnover. Design: Cross-sectional analysis of employee-level payroll data from the Centers for Medicare and Medicaid Services, examining facility-level annual staff turnover and the proportion of residents with SMI derived using the Minimum Data Set 3.0, adjusting for other facility, resident, and county characteristics. Setting and participants: US nursing homes in 2022 (N = 14,124). Methods: Linear mixed models with states as random intercepts. Dependent variables were annual turnover for nursing aides, licensed practical nurses, registered nurses, and nurse administrators. The primary exposure variable was the proportion of residents with SMI, categorized into 4 groups. Control variables included facility and resident characteristics, and employee hours per resident day. Results: The interquartile range for the percent of residents with SMI is 5.0% to 15.1%. Average annual turnover exceeded 50% for all staff types; registered nurses and nurse administrators had the highest turnover (54.1%; 95% CI, 53.7%-54.5% and 95% CI, 53.6%-54.6%, respectively). High SMI serving nursing homes generally had higher unadjusted turnover than low SMI serving facilities. Adjusting for covariates, however, there was no consistent relationship between SMI proportion and turnover within or between staffing roles. For example, relative to SMI quartile 1, turnover was higher for licensed practical nurses in quartile 2 (50.2%; 95% CI, 48.8%-51.6% vs 49.0%; 95% CI, 47.5%-50.5%; P = .03), for registered nurses in quartile 4 (53.9%; 95% CI, 52.3%-55.5% vs 51.6%; 95% CI, 50.2%-53.1%; P < .01), and for nurse administrators in quartile 3 (53.1%; 95% CI, 51.4%-54.9% vs 51.3%; 95% CI, 49.6%-53.1%; P = .02). Conclusion and implications: Nursing home staff turnover rates were high across staff types with no meaningful relationship or consistent trends between the proportion of residents with SMI and staff turnover. Nursing homes might focus on other factors when developing strategies to reduce turnover, rather than those specific to residents with SMI.