“I think the movement to improve the nursing home as a workplace and the movement to improve it as a place to live are coming together in a very positive way, so that a nursing home can be both a better place to live and to work,” says Thomas Konrad. “I think those tendencies reinforce each other.”

Konrad is one of the authors of the Workplace Interventions, Turnover, and Quality of Care Report (pdf) released in June 2009 that details the effects of three distinct workplace interventions aimed at improving staff turnover rates and quality of care in North Carolina’s nursing homes.

These interventions include:

• The WIN A STEP UP program, a partnership of UNC’s Institute on Aging (IOA) and the North Carolina Department of Health and Human Services. The program addresses nurse aide recruitment and retention by providing education, training, and monetary rewards for aides who complete it. It also requires PHI Coaching Supervision^SM training for nurse aide supervisors at participating homes.
• Quality improvement collaboratives (QIC), in which groups of nursing homes work together with the statewide Quality Improvement Organization to improve specific quality indicators like reducing pressure sores or eliminating use of restraints.
• Culture change initiatives, grant-funded programs that enable nursing homes to implement changes designed to make their environments more homelike.

From 2004 to 2007 these programs were implemented at various nursing homes in North Carolina and then analyzed by IOA using quality indicators from the Nursing Home Compare (NHC) data set provided by CMS. In the end the results were clear: staff turnover and quality of care were both improved.

Of the three interventions, WIN A STEP UP proved to have the most direct impact on staff retention.

“WIN A STEP has a threefold approach,” says Konrad. “One is recognition of the workers. The second is skills training and career building, which involves [financial] rewards. … The third part is an accountability commitment.”

The result, he said, is an increase in team spirit between frontline workers and supervisors, improvement of clinical skills, and improvement of “soft skills” such as communication and interpersonal dealings, all of which leads to improved retention rates and quality of care, as seen in, for example, an observed decrease in incidents of dehydration and pressure sores.

A Virtuous Circle

“I don’t think you can improve quality without reducing turnover,” Konrad said. “And the relationship seems to go both ways. That is, frontline workers and supervisors don’t want to work in a place that doesn’t have high quality, so both contribute to raising that quality.

“Furthermore, as a nursing home improves its quality it builds commitment in the staff. So it can be a virtuous circle, although we see the opposite process occurs too often in some nursing homes.”

Konrad emphasized that none of the positive results reported in the study should be taken as cause for complacency. “We still have an unacceptably high turnover rate in North Carolina,” he says. “Unless the kind of changes we saw with WIN A STEP UP and other such things are institutionalized and carried on, turnover can go right back up.”