Tackling high staff turnover in long-term care settings in the US

How a 12-month new-graduate nurse-residency programme is helping to change how community care providers attract and retain staff

How a 12-month new-graduate nurse-residency programme is helping to change how community care providers attract and retain staff

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By 2050, the number of people in the US aged 65 or older is projected to be nearly twice what it was in 2012, 43.1 million.

This demographic shift will place intense stress on our healthcare system as older people tend to experience more chronic conditions and disability. It also raises a question about whether the long-term care (LTC) industry will be ready to meet the challenge.

It is well established that there is a high turnover of staff in the LTC industry, and that this negatively affects patient outcomes (Bae et al 2010, Castle and Anderson 2011).

A report from the San Francisco Health Workforce Research Center states that workers are leaving LTC faster than they are entering (Frogner and Spetz 2015), a major problem in an industry that is projected to grow substantially over the next three decades.

The LTC industry has set goals nationally to ‘reduce turnover rates among nursing staff by 15%, or achieve or maintain at no more than 40% turnover rate by March 2018’ (American Health Care Association (AHCA) 2017).

While the AHCA’s recognition of the problem is laudable, a 40% turnover rate would still create an unstable environment for staff.


High turnover is a problem, not only with nurse staffing, but also among directors of nursing.

Where I work, in New Jersey, for example, there is a 38% turnover rate of directors of nursing. We have begun to address this by working with the Health Care Association of New Jersey and through our New Jersey Action Coalition.

We have also obtained funding from the Centers for Medicare and Medicaid Services to initiate a 12-month new-graduate nurse-residency programme (Cadmus et al 2016).

As part of this initiative, we have drawn up a curriculum for transition-to-care programmes and to support continuing education.

Over one year, the programme demonstrated an 86% retention rate (Salmond et al 2017), which has allowed us to secure funding for an additional year to continue and expand the programme.

Many organisations do not take advantage of the new-graduate nurse-residency programmes, however. 

The LTC industry argues that reimbursement structures do not offer staff opportunities to attend these programmes, but this does not take into account the amount of money spent on recruitment and how much this sum could be reduced if turnover rates were lower.

New nurses are looking for opportunities for advancement, as well as new experiences, balanced work-life and a sense of meaningful work.

If nurse graduates do not foresee they can achieve these personal goals in LTC settings, they will be reluctant to take positions in them.


To attract and retain nursing staff, LTC structures must change. LTC employers need to offer opportunities that acute care facilities have offered to registered nurses for a long time. 

These include promotional opportunities through a clinical-ladder model, shared governance structures in which staff can engage in decision-making committees that provide meaning to their work, and tuition assistance programmes so they continue to learn and develop. 

All of these aims can be achieved if we work together. The care that older adults need and deserve will require a change in mindset on how to recruit and retain nursing staff.


About the author

Edna Cadmus is executive director of the New Jersey Collaborating Center for Nursing, Rutgers School of Nursing

Edna Cadmus, Susan Salmond, Katherine Kuren Black, Nancy Bohnarczyk and Linda Hassler are authors of Developing a Residency in Post-acute Care, published by Sigma Theta Tau International

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