High turnover of caregiving staff in nursing facilities and poor quality of care have been reoccurring matters of public concern, policy debate, and research for several decades (Eaton, 2000; Mukamel et al., 2012; Rosen, Stiehl, Mittal, & Leana, 2011; Walshe, 2001). Since the 1970s, studies have reported average annual turnover rates for registered nurses, licensed practical nurses, and certified nursing assistants (CNAs) ranging from 55 to 100%, with turnover rates as high as 400% for CNAs in some facilities (Castle & Engberg, 2005; Mukamel et al., 2009). Because CNAs function as "frontline" caregivers, the effects of high turnover among these workers are particularly pervasive and include compromised quality of care, high replacement costs, lost productivity, and low morale (Stearns & D'Arcy, 2008). Due to the important role that CNAs play in the nursing facility care continuum, nearly all state Medicaid agencies and departments of aging consider CNA turnover to be a major workforce issue (Castle, 2008). In response, various interventions have been implemented to reduce CNA turnover and improve quality of care in nursing facilities (Lehning & Austin, 2010; Mukamel et al., 2009).
The present study was undertaken to evaluate one such intervention, entitled the Virginia Gold Quality Improvement Program, implemented by the Virginia Department of Medical Assistance Services (i.e., Virginia Medicaid) in five nursing facilities. The evaluation had three unique features. First, the study represented a longitudinal qualitative evaluation of Virginia Gold because it was a continuation of an earlier investigation (Craver & Burkett, 2012). Second, the evaluation assessed the overall influence of Virginia Gold on turnover and care quality from the perspectives of both CNAs and residents and supplemented this assessment with quantitative data. Finally, the evaluation examined efforts by managers at the nursing facilities to continue the quality improvement projects one year following Virginia Gold's culmination.
Nursing facility care is labor intensive and time consuming because the individuals who reside in these facilities are mostly frail adults with cognitive and/or physical disabilities that become more individualized as they age. Complicating this further is that many residents have at least one comorbid chronic disease along with an accompanying set of unique social circumstances that require continuous attention if they are to achieve an acceptable quality of life (McConnell, Lekan, & Corazzini, 2010). Within nursing facilities, CNAs provide approximately 80% of the paid care (e.g., measuring vital signs) and personal assistance (e.g., assistance with eating, bathing, and dressing) that residents need (Castle, 2012). While they perform an important role in the nursing facilities, many CNAs experience stressful working conditions that require a considerable amount of emotional labor on a near-constant basis, receive low pay and limited benefits, and have few opportunities for career advancement or alternative employment (Eaton, 2000; Morgan & Konrad, 2008). Not surprisingly, these conditions contribute to unstable workforce recruitment and retention problems for nursing facilities that manifest themselves in high CNA turnover rates (Stearns & D'Arcy, 2008).
Many observers view high CNA turnover as a significant public policy issue that will likely increase as the demand for nursing facility services intensifies due to the growing number of aging baby boomers in the United States (Dill, Morgan, & Konrad, 2010; Lehning & Austin, 2010; Rosen et al., 2011; U.S. Department of Health and Human Services [USDHHS], 2011). High CNA turnover has several far-reaching consequences, such as increased costs for nursing facilities, but the most serious consequence is the potential for adverse health outcomes for residents because high turnover can influence quality of care through several mechanisms. …