Poor Management Skills: “A Contributing Factor to High Turnover Rate in Nursing Homes”
Obianuju C Efobi
*Corresponding author: Obianuju C Efobi
Received: 15 April 2022; Accepted: 23 April 2022; Published: 30 April 2022
Citation: Obianuju C Efobi. Poor Management Skills: “A Contributing Factor to High Turnover Rate in Nursing Homes”. Fortune Journal of Health Sciences 5 (2022): 232-242Share at Facebook
Undeniably, long-term healthcare facilities have been linked to having high turnover rates and this, in turn, hurts the company’s resources and the quality of care for senior citizens. Stabilizing the workforce and updating training standards are imperative to reforming long-term healthcare facilities and support systems in the United States. This retrospective quantitative study aims to analyze if there are connections between employee turnover and poor organizational skills in nursing homes. Employees of concern are caregivers employed in the homecare industry in various parts of the USA. Further analysis of several materials implied that there is a negative link between employee turnover and poor management skills. Moreover, an increase in turnover rate impacts the organization in different ways as the organization loses the expertise of experienced employees and its reputation in the community. The conclusion of this study suggested that managers must switch leadership styles to create a conducive environment for employees which will lead to plummeting figures in caregiver turnover rates, which will ultimately stabilize the physical well-being of residents.
USA; CNAs; employees; argued
Direct caregivers, like health care aides, serve a fundamental purpose in assisted living facilities providing daily assistance to the elderly living in long-term care facilities around the world . Over the years, many nursing homes experience high turnover rates which have led to excessive employee workload and the premature death of residents . Employee turnover has become a frequent and costly challenge in several nursing homes and assisted living facilities. There have been lots of debates on whether high turnover rates are due to poor management skills or other reasons within the healthcare facilities. Research by , indicated that high turnover rates amongst nursing assistants occur as a result of the never-ending supply of staff in the nursing home while other studies argued that it was due to scheduling of shifts that disrupted employee’s lives. A survey by  stated that poor management practices have led to low staff retention rate, examples of these practices include averting salary increases, recruiting at a slower pace, paying low wages with no benefit, lack of assistive work equipment, inadequate staff, and lack of career development programs.
For most managers, a high turnover rate is never an issue to them because there will always be individuals willing and ready to work. However, residents are dissatisfied because they are familiar with these caregivers, and the replacement of staff each time can be annoying alongside emotionally distressing . Discussions regarding this issue are often neglected because home healthcare workers are categorized within the under-skilled category . Classifying these groups of employees as under-skilled workers results in their low wages, low training costs, and a little supply of workers to fill new positions. Past researchers gathered concrete reasons for direct caregivers’ turnover but did not attribute it to poor managerial skills.
This retrospective quantitative study seeks to discover the effects of poor managerial skills on employees and to assess if employees still quit regardless of conducive working conditions. It also aims to uncover strategies on how to maintain employee turnover rate to a minimal level. Data was collected based on surveys offered to CNAs to assess employees’ perceptions surrounding the inadequacies of management skills. Assumptions on the right set of questions were added in the questionnaires for data collection. The SWOT analysis will be utilized to analyze the threats high turnover plays on these organizations while the solutions will be explained using Cohen’s eight-step model for change. There were a limited number of peer-reviewed and recent articles relating to this study.
2. Evaluation Questions
Does poor managerial skill lead to an “increase in the turnover rate”?
What are examples of poor managerial skills relating to a high turnover rate?
What evidence is available to support this statement?
Effects of low employee retention rate on the organization?
What model of solutions can improve turnover?
Hypotheses- Is there any relationship between poor management skills and high turnover?
3. Review of Literature
One of the most critical challenges faced by nursing homes is the low retention rate of CNAs . The managers of these facilities continually hire; however, these employees do not remain for long. Caregivers are the essential strata in elder care facilities as they contribute to the success of the business and the physical well-being of the patients . Different research by  suggested that the primary reason for high turnover rates is due to low performance and motivation because these sets of employees were not qualified for the real task of the job , indicated that organizations that do not purchase work improvement equipment, would likely experience high turnover rates and loss of resources due to compensation fees and recruiting fees. Further studies agreed that healthcare institutions with work improvement equipment had caregivers with reduced stress levels; therefore, employees felt safe and comfortable while handling tasks. Also, these employees didn’t lose workdays or quit due to musculoskeletal aches, back injuries, or major healthcare reasons.
The occurrence of work-related injuries plays a significant role in staff retention. “According to the “CDC (2008), about 70% of 304,400 CNAs indicated that they left their jobs because the policies of the nursing homes were not appropriate to them and there were no direct communications either with colleagues or managers. This report suggested that workers preferred to explore more suitable employment opportunities or forfeit their employment because of the toxic work environment. The cost of turnover is expensive and results in low productivity, overworked staff, and hiring costs .
The administrators struggle with monetary constraints, and can’t offer to increase employees' pay to stay. Fiscal issues are simple problems and cannot be compared with problems surrounding employee performance and retention; hence managers should not neglect their effect . Ther-efore, managers have to implement strategies to improve employee retention rates by improving motivation and satisfaction at the place of work . Long-term care administrators experience a lot of stress and difficulties in keeping their programs running . After analyzing several works of literature, one can conclude that there is a direct link between increased turnover rate and poor managerial skills, therefore administrators must create a positive work environment for employees to thrive .
This study is a quantitative retrospective research method. Materials relating to this study were pulled from the online library and google scholar. The paper is organized into four parts. The first part involves a review of high turnover. This section gives details on the severity of the turnover and how universal it has become in the States and various parts of the world. The second part focuses on the perceived reasons for high turnover rates. Few studies outline why an organization will experience high turnover due to poor management skills.
The third part highlights the impact or threats an organization faces due to high turnover. These topic areas will focus on the following issues: How it affects the organizations’ reputation and resources? The fourth and final section of this paper suggests strategic solutions and a plan to increase low retention rate in the profit health sector. Nonetheless, it should be known that recent research regarding this topic is limited and thoughtful consideration and cautions were involved when communicating with patients and employees.
4.1 Nursing homes, Residents, Managers and Caregivers
The aging population is a continuously growing sector of American society [14, 15] and will need to be cared for in the future. About 40 million senior citizens, at the age of 65 years, depend on the assistance of caregivers for their daily activities while about 1.2 million individuals at the age of 85 receive complex care with the aid of caregivers due to severe medical conditions “’’ . Nurses in hospitals find it difficult to transfer into aged care due to high salaries and better career pathways provided in other healthcare settings . There are future predictions that there will be an increase in the aging population; hence the number of employees needs to increase.
For this reason, a sustainable and skilled workforce will be essential to cater to the needs of the increasing population. Therefore, administrators of nursing homes must improve employee retention rates by fixing policy issues concerning turnover .
Despite the growing emphasis on improving turnover rates in nursing homes, virtually no research has explained the issue concerning poor operations of the nursing homes . The study by  showed that nursing home administrators who filled management positions have little education but more significant experience especially due to ownership status. Another study by the “Association of University Programs in Health Administration [AUPHA] 2010”, argued that the enrollment rate of "Health Management" programs in universities has declined, so this might be the reason for the poor skills of long-term care administrators.
Employees of chained-owned or family-owned facilities described that they experience increased work pressure than those working in state-owned facilities and the wages were negligible of the high-stress levels. Results after research were carried out by  concluded that for-profit nursing homes administrators have little experience when compared to administrators from other sectors which results in poor employee quality. More educational preparation and experience in nursing homes will lead to better patient outcomes and a reduction in nursing homes death [20, 21].
4.2 Causes of High Turnover Due to Poor Management Skills
4.2.1 Poor communication skills of managers:
Research by  identified the presence of a relationship linking employee communication and quitting in the eldercare industry. Employees tend to leave their jobs, once they perceive their leaders do not support them. A different study discovered that when employees feel secluded from information or training, they perform poorly and finally leave .
4.2.2 Lack of equipment in nursing homes:
Nursing homes are one of the most dangerous work sectors within the healthcare institutions due to the strenuous activities that go on there. Nursing homes employees suffer from musculoskeletal problems which are the principal reason for the voluntary turnover rate  confirmed that the management of these organizations wants to increase profit at all cost and refuse to purchase transfer equipment and supplies, which hinders employees from performing effectively . Many employees complain that work policies in this facility are not illegal but unethical and lack employee consideration .
4.2.3 Inadequate staffing:
Most nursing homes have Four residents to One caregiver ratio in their organizations' policy irrespective of size or weight, but with inadequate staffing the ratio increases then employees are stressed and burn-out, especially in smaller facilities that pay little wages . Nevertheless, administrators of these healthcare institutions understand the importance of safe staffing and its significance to patients' safety and care; nonetheless, various reasons prevent organizations from changing policies.
4.2.4 Lack of satisfaction:
Work by , as cited in , discovered that uncomfortable work environments increase employees' decisions to quit the organization. Results by  also strengthened these statements that increased stress and no empowerment programs in the work environment can push the desire of individuals to leave.
4.2.5 Workplace assault & aggression:
Nursing home caregivers experience an extreme level of violent attacks at work and this level of violence experienced surpasses that of other health care professionals . These employees express plans to leave the health sector or switch organizations. According to , these employees confirmed that managers accept all patients irrespective of unattainable employee specialized skills.
4.2.6 Lack of empowerment skills:
Some managers of these institutions act as dictators directing all operations to employees . This method of leadership does not create room for empowerment and retention of employees .  argued that employees of these facilities are not involved in the discussion concerning work changes or decisions, especially when the demands of the manager on these employees are unrealistic. Administrators of these organizations never consider the opinions and contributions of their employees and rarely give recognition or show appreciation to employees. Caregivers are not authorized to execute their skills, and slowly begin to feel the loss of work morale, reduce productivity and finally quit their job.
4.3 Impacts of Turnover in the Organization
Low employee retention directly affects healthcare institutions. The actual reason for turnover must be detected to diminish the rate of workers that quit an organization and explore other forms of employment. Several organizations employ hardworking staff but neglect implementing strategies on how to retain this staff. The effect of voluntary turnover is unimaginable; its effects are felt in all aspects of the working environment ranging from employee performance to the quality of care for residents .
Lots of revenues are lost, taking into consideration compensation fees for injuries, labor time, and overtime fees; moreover, the cost of advertisement, reviewing applications, and training cannot be overlooked. Increasing employee retention will improve work-related stress and reduce the loss of organizations' savings . Therefore, administrators must acknowledge the implications of high turnover rates on the organization’s finances and reputation.
4.3.1 Bad attitude and Lack of motivation:
 agreed that employee turnover leads to exhaustion of motivation and a bad attitude in the workplace. Some researchers say this is normal; humans are lazy or sluggish after carrying out the monotonous function every day, especially in stressful and unchanging conditions, especially in stressful and unchanging conditions. Overworked staff and new employees who experience this increased responsibility finally quit because they struggle with learning new duties assigned to them. Managers of this organization will have a difficult time attracting and keeping talent since they did not change their method of operations.
4.3.2 The Decline in Care and Emotional Support for Residents:
Shortage of employees can lead to the poor emotional support of residents since these employees work quickly to finish their jobs, also, these employees do not evaluate the emotional condition of the residents but depend on only the clinical symptoms of patients to determine if residents are sick. Extensive research of various works established the linkage between low employment levels and the outcome of care in residents of long-term facilities. Employees tend to make mistakes losing important information concerning the welfare of the patients. Furthermore, the facility might face penalties and fines when inspectors and regulatory agencies identify health and quality deficiencies.
4.3.3 Loss of Residents to other facilities:
New clients make a decision not to live in these organizations because of the negative reputation and reviews of the nursing homes within the society. Already these organizations experience loss of revenue due to high turnover, over a longer duration, the financial instability of the organization reduces the agency’s ability to achieve new residents .
4.3.4 Loss of indirect costs and Profits:
Indirect resources cannot be measured by physical cash; instead, they can be determined by assessing the performance and ability of the departing employee. It is the indirect cost that eventually affects the revenues through the resident's comfort and satisfaction . These indirect costs are harmful in healthcare organizations where productive capacity such as abilities, knowledge, and skills are essential for the care of patients.
4.3.5 Third-party suffers the cost:
Inadequate care of the elderly leads to the prevalence of secondary illness, which increases emergency visits, admission days, and mortality rate. These events push the risk to public insurance programs and drain the country's health budget. According to , taxpayers incur most of these expenses.
5. Proferred Solutions
Employers must acknowledge areas of concern of employees, before strategies to reduce turnover are implemented. Managers should review the organization’s hiring practices, and style of leadership and then own up to their responsibility . According to , managers must take action to solve issues concerning the high turnover rates Frequent assessment of working conditions and limitations of workplace injuries will serve as useful policy tools. Most importantly, managers should not solely rely on financial incentives to curb these issues because it is not a sustainable solution. As challenging as it may be, something must be done to improve managerial skills in nursing homes.
5.1 Changing of leadership style:
Employees can switch leadership styles by focusing on the well-being of their employees. Good leaders always strive to improve the work-balance of their employees by providing support to and serving their employees [38, 39] encourages leaders to utilize morals, values, and respect while leading because leadership can only be built on virtue and ethics (p. 2).  insist that “values-dependent leadership” can influence workers’ attitudes and behaviors.
5.2 Purchasing work improving equipment:
 argued that work assistive equipment creates safe working conditions. Also, this equipment will be beneficial to the physical well-being and continuous care of residents.
5.3 Increasing their level of Engagement:
Managers must improve their skills through proper communication and engagement with employees, which will, in turn, increase employees’ commitment to the organization   suggested that employers can stop practices like little training time and poor engagement. A survey carried out by  showed that employers who coached, engaged, and paid attention to the employees’ challenges in work indirectly improved the chances of their learning. Highly-skilled managers encourage and drive employees to be better and stay with the company. Managers with integrity and that are trustworthy are essential for business .
5.4 Increase Staffing level:
Martin& Ramos (2017) agreed that reinforcement of adequate staffing levels would reduce the possibility of employees leaving since both employees and residents will benefit from this . Although this solution is expensive, it will assist to reduce the organization’s reputation since the president’s health remains perfect. A different study agreed that organizations with better staffing ratios had residents that recover or stabilize after an illness .
5.5 Employing skilled workers:
This can assist in reducing workplace assault from residents since they are well-prepared to handle any situation. Recruiting employees who are interested in that position and training both new and old employees with the necessary skills will improve working conditions . Also, administrators can perform evaluations to understand what skills employees’ lack.
5.6 Recognition/ Reward and Employer’s Consistency:
 suggested that employees can create a recognition reward system to appreciate employees for their performance. These reward systems can be done through giving finances, praises, or gifts. Furthermore, employees are advised to be consistent with decisions concerning the operations of the organization (Wiley, 2011).
6. Swot Analysis for Poor Management Skills
Opportunity to get well trained staff.
Low job satisfaction.
Difficult to receive new clients.
Loss of skilled staff.
Creates room for improvement.
Manager begins to engage with employees.
Competitors accept new clients.
Possibility of closure.
Fine and litigation charges.
Damaged Reputation to the community.
Have to increase wages.
The rate of employee retention in private nursing homes is low, after reviewing several studies and high turnover rate harms the organization. Therefore, lowering staff turnover and increasing staff retention should be the manager's primary focus. Facilities with higher staff turnover must improve to allow fostering of relationships between employees and residents of the organizations. Issues like dissatis-faction can be resolved quickly through recognition programs, where employers acknowledge employees and performance (Borkowski et al. 2007).
The results of this study show that administrators and employees have a huge role to play in reducing the rate of turnover. In conclusion, there are usually six factors that will determine an employee’s decision to leave or stay which are: “monetary rewards, type of job, career growth, employee recognition, organization’s management and work-life balance” .
There are several constraints to this study. First, this study is a cross-sectional that focused only on the correlation between poor management skills and employees' turnover. Therefore, there will be no suggestion on the influence of higher wages on reducing turnover rate.
Furthermore, there were few peer-reviewed and recently published articles on turnover in nursing homes. Also, studies relating to poor management skills were limited because of selection-biased. Lastly, no theoretical framework was relevant to this study.
There are various studies regarding employee turnover in nursing homes; however, additional studies are required to understand how managers can improve their skills to reduce the vicious cycles of increase in turnover rates. Even though high turnover rates cannot be solved entirely, further studies on resolution strategies and its utilization would assist managers in implementing strategies on reducing the turnover rate in their organizations.
The Administrator’s perspective concerning the reason and outcome of turnover will serve as a better approach to further exploring issues with turnover.
- Khatutsky G, Wiener JM, Anderson WL, & Porell FW. Work-related injuries among certified nursing assistants working in US nursing homes. Research Triangle Park, NC: RTI Press (2012).
- Hodgkin S, Warburton J, Savy P, & Moore M. Workforce crisis in residential aged care: insights from rural, older workers. Australian Journal of Public Administration 76 (2017): 93-105.
- Mukamel DB, Spector WD, Limcangco R, Wang Y, Feng Z, & Mor V. The costs of turnover in nursing homes. Medical care 47 (2009): 1039.
- Cahill DJ. Top Five Turnover Causes in Healthcare. HSD METRICS.
- Barbera FE. The keys to reducing turnover in long-term care. Long term care news.
- Kayyali A. The impact of turnover in nursing homes. American Journal of Nursing 114 (2014): 69-70.
- Squires J, Hoben M, Linklater S, Carleton H, Graham N, & Estabrooks C. Job satisfaction among care aides in residential long-term care: A systematic review of contributing factors, both individual and organizational. Nursing Research and Practice (2015): 1-24.
- Negarandeh R. Enhancing transition to workplace. Nursing and Midwifery Studies 3 (2014): 1-2.
- Silverstein B, Howard N, & Cullen J. Lifting patients/residents/clients in health care Washington State 2005. Report to the Washington State Legislature House Commerce and Labor Committee, Olympia WA (2006).
- Kim S. The impact of human resource management on state government IT employee turnover intentions. Public Personnel Management 41 (2012): 257-279.
- Skirbekk H, & Nortvedt P. Inadequate treatment for elderly patients: Professional norms and tight budgets could cause “Ageism” in hospitals. Health Care Analysis 22 (2014): 192-201.
- Lerman RI, Eyster L, & Kuehn D. Can we upgrade low-skill, low-wage occupations? The case of apprenticeships in the long-term care occupations. Journal of Women, Politics & Policy 35 (2014): 110-132.
- Ghorbanian A, Bahadori M, & Nejati M. The relationship between managers’ leadership styles and emergency medical technicians’ job satisfaction. Australasian Medical Journal 5 (2012): 1-7.
- King D, Mavromaras K, Wei Z, He B, Healy J, Macaitis K, et al. The Aged Care Workforce Final Report 2012 (2013).
- McQueen E. Humor-related social exchanges and mental health in assisted living residents (Doctoral dissertation). Available from Pro Quest Digital Dissertations and Theses database (AAT 299) (2012).
- Federal Interagency Forum on Aging-Related Statistics. Population (2013).
- Senate hears workforce crisis in aged care. Australian Nursing and Midwifery Journal 24 (2017): 4-4.
- Alterman T, Baron S, Calvert G, Sweeney M & Tak S. Workplace assaults on nursing assistants in us nursing homes: A multilevel analysis. American Journal of Public Health 100 (2010): 1938-45.
- Decker FH, & Decker SL. Experience and education of home health administrator’s and nursing home administrator’s and the relationship to establishment ownership. Journal of Health and Human Services Administration (2012): 149-169.
- Castle NG, & Decker FH. Top management leadership style and quality of care in nursing homes. Gerontologist 51 (2011): 630-642.
- Forbes-Thompson S, Gajewski B, Scott-Cawiezell J, & Dunton N. An exploration of nursing home organizational processes. Western Journal of Nursing Research 28 (2006): 935-954.
- Zhang NJ, Unruh L, & Wan TT. Gaps in nurse staffing and nursing home resident needs. Nursing Economics 31 (2013): 289-297.
- Frey RV, Bayón T & Totzek D. How customer satisfaction affects employee satisfaction and retention in a professional services context. Journal of Service Research 16 (2013): 503-517.
- Woodhead EL, Northrop L & Edelstein B. Stress, social support, and burnout among long-term care nursing staff. Journal of Applied Gerontology (2014): 1- 22.
- Nooney J & Unruh L. Newly licensed registered nurses’ perceptions of job difficulties, demands and control: Individual and organizational predictors. Journal of Nursing Management 19 (2011): 572-584.
- Castle NG & Donoghue C. Voluntary and involuntary nursing home staff turnover. Research on Aging 28 (2006): 454-472.
- Gruss V, McCann JJ, Edelman P, & Farran CJ. Job stress among nursing home certified nursing assistants: Comparison of empowered and nonempowered work environments. Alzheimer's Care Today 5 (2004): 207-216.
- Gerberich SG, Church TR, McGovern PM, Hansen HE, Nachreiner NM, Geisser MS, et al. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses’ Study. Occupational and environmental medicine 61 (2004): 495-503.
- Wallis A, & Kennedy KI. Leadership training to improve nurse retention. Journal of Nursing Management 21 (2013): 624-632.
- Hilton T. Effect of burnout and organizational commitment on the turnover intention of clinical laboratory employees in Florida. (Doctoral dissertation) (2015).
- Rafiee M, Kazemi H, & Alimiri M. Investigating the effect of job stress and emotional intelligence on job performance. Management Science Letters 3 (2013): 2417– 2424.
- Gawali V. Effectiveness of employee cross-training as a motivational technique. ASBM Journal of Management 2 (2009): 138-146.
- Seavey D. The cost of frontline turnover in long-term care (pp. 1-3). Washington, DC: Better Jobs Better Care (2004).
- Waldman J. Deanne et al. “The Shocking Cost of Turnover in Health Care.” Health Care Management Review 29 (2004): 2-7.
- Dawson, Steven and Rick Surpin. Direct-Care Health Workers: The Unnecessary Crisis in Long-Term Care. A Report submitted to the Domestic Strategy Group of the Aspen Institute by PHI (2001).
- Cohen-Mansfield J. Turnover among nursing home staff: A review. Nursing management 28 (1997): 59.
- Tsai YH, Huang N, Chien LY, Chiang JH, & Chiou ST. Work hours and turnover intention among hospital physicians in Taiwan: does income matter? BMC health (2016).
- Scott H, Carr-Chellman DJ, & Hammes L. Profound Leadership: An Integrative Literature Review. The Journal of Values-Based Leadership 13 (2020): 11.
- Rao M. Values-based leadership. The Journal of Values-Based Leadership 10 (2017).
- Nygaard A, Biong H, Silkoset R, and Kidwell RE. Leading by example: Valuesbased strategy to instill ethical conduct. Journal of Business Ethics 145 (2017): 133-139.
- Trinkoff AM, Johantgen M, Muntaner C & Le R. Staffing and worker injury in nursing homes. American journal of public health 95 (2005): 1220-1225.
- Jones J. How to reduce employee turnover in the cleaning industry. Demand Media (2011).
- Bagraim J, Cunningham P, Potgieter T, Viedge C. Organizational Behavior: A contemporary south african perspective (2007).
- Aguenza BB, & Som APM. Motivational Factors of Employee Retention and Engagement (2012).
- Association of University Programs in Health Administration. Enrollment Trends, 1991-2010 Arlington (2010).
- Bryant OA. Employee turnover in the long-term care industry (2017).
- Centers for Diesease Control and Prevention (CDC). Health United States, 2008, Tables 94,102,106 (2008).
- Farren C. Managers: A Key Factor in Employee Retention and Engagement (2008).
- Herzberg F, Mausner B, & Snyderman B. The motivation to work (2nd ed). New York, NY: Wiley & Sons (1959).
- Philip NS. Exploring holistic nurse manager roles with new patient satisfaction dimensions and expectations (Doctoral dissertation) (2014).