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Turnover, Staffing, Skill Mix, and Resident Outcomes in a National Sample of US Nursing Homes

Trinkoff, Alison M. ScD, RN; Han, Kihye PhD, RN; Storr, Carla L. ScD; Lerner, Nancy DNP, RN; Johantgen, Meg PhD, RN; Gartrell, Kyungsook MS, RN

Journal of Nursing Administration: December 2013 - Volume 43 - Issue 12 - p 630–636
doi: 10.1097/NNA.0000000000000004

OBJECTIVES: The authors examined the relationship of staff turnover to selected nursing home quality outcomes, in the context of staffing and skill mix.

BACKGROUND: Staff turnover is a serious concern in nursing homes as it has been found to adversely affect care. When employee turnover is minimized, better care quality is more likely in nursing homes.

METHODS: Data from the National Nursing Home Survey, a nationally representative sample of US nursing homes, were linked to Nursing Home Compare quality outcomes and analyzed using logistic regression.

RESULTS: Nursing homes with high certified nursing assistant turnover had significantly higher odds of pressure ulcers, pain, and urinary tract infections even after controlling for staffing, skill mix, bed size, and ownership. Nurse turnover was associated with twice the odds of pressure ulcers, although this was attenuated when staffing was controlled.

CONCLUSIONS: This study suggests turnover may be more important in explaining nursing home (NH) outcomes than staffing and skill mix and should therefore be given greater emphasis.

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Author Affiliations: Professor (Drs Trinkoff and Storr), Assistant Professor (Dr Lerner), Associate Professor (Dr Johantgen), and PhD candidate (Ms Gartrell), School of Nursing, University of Maryland, Baltimore Maryland; Assistant Professor (Dr Han), Red Cross College of Nursing, Chung-Ang University, Seoul, South Korea.

This study was funded by the National Council of State Boards of Nursing Grant R40009 (to Dr Trinkoff, principal investigator).

The authors declare no conflicts of interest.

Correspondence: Dr Trinkoff, School of Nursing, University of Maryland, 655 W Lombard St, Room 625, Baltimore, MD 21201 (

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins