report released in 2001 by the Centers for Medicare and Medicaid Services (CMS), which investigated the appropriateness of minimum nurse staffing ratios in nursing homes, noted the following:

[W]ith one nursing assistant commonly responsible for nine or more residents on the day shift and twice as many at night, time management often degenerates into triage. Baths and meals are given on a tight schedule and at the convenience of the home’s routine rather than the residents, leading to things like waking residents in the middle of the night for showers. Call lights are left unanswered, nonessential tasks such as nail care are neglected, and practices are often adopted that endanger either residents or staff. (CMS, 2001)

Conversely, improving some aspects of job quality (e.g., reducing turnover) may lead to improvements in the quality of patient care. For example, allowing nurse aides to have greater responsibility in care decisions is associated with higher social-engagement scores among patients, and lower rates of turnover and higher rates of retention have been associated with lower incidence of pressure ulcers (Barry et al., 2005). One study of residents and staff at assisted-living facilities found that a high-quality work environment, including an organizational culture that emphasizes teamwork and participatory decision-making, is associated with greater satisfaction among the residents (Sikorska-Simmons, 2006). Another study examined a skilled nursing facility that had created a staffing program that emphasized consistent scheduling, with staff permanently assigned to specific residents. The facility reported that the program had positive effects both on worker satisfaction (including a 10 percent decrease in turnover and a 50 percent decrease in injuries) and on patient outcomes (including a 40 percent decrease in pressure ulcers and an 83 percent decrease in complaints) (ASA, 2008). Again, however, it is difficult to prove a causal relationship between job satisfaction and turnover and the consequent effects on patient care. Strategies to improve the quality of direct-care jobs and the effects of these strategies on reducing turnover and increasing intent to stay are discussed in the next section.


In order to overcome the challenges to recruitment and retention of direct-care workers, more needs to be done to improve the overall quality and, therefore, desirability of these jobs. Strategies to do this can be grouped into three broad categories:

  • Enhancing the quality and quantity of basic education and training

The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement