Association between nursing home staff turnover and infection control citations

Abstract

Objective: To describe the association between nursing home staff turnover and the presence and scope of infection control citations.

Data sources: Secondary data for all US nursing homes between March 31, 2017, through December 31, 2019 were obtained from Payroll-Based Journal (PBJ), Nursing Home Compare, and Long-Term Care: Facts on Care in the US (LTC Focus).

Study design: We estimated the association between nurse turnover and the probability of an infection control citation and the scope of the citation while controlling for nursing home fixed effects. Our turnover measure is the percent of the facility's nursing staff hours that were provided by new staff (less than 60 days of experience in the last 180 days) during the 2 weeks prior to the health inspection. We calculated turnover for all staff together and separately for registered nurses, licensed practical nurses (LPNs), and certified nursing assistants.

Data collection/extraction methods: We linked nursing homes standard inspection surveys to 650 million shifts from the PBJ data. We excluded any nursing home with incomplete or missing staffing data. Our final analytic sample included 12,550 nursing homes with 30,536 surveys.

Principal findings: Staff turnover was associated with an increased likelihood of an infection control citation (average marginal effect [AME] = 0.12 percentage points [pp]; 95% confidence interval [CI]: 0.05, 0.18). LPN (AME = 0.06 pp; 95% CI: 0.01, 0.11) turnover was conditionally associated with an infection control citation. Conditional on having at least an isolated citation for infection control, staff turnover was positively associated with receiving a citation coded as a "pattern" (AME = 0.21 pp; 95% CI: 0.10, 0.32). Conditional of having at least a pattern citation, staff turnover was positively associated with receiving a widespread citation (AME = 0.21 pp; 95% CI: 0.10, 0.32).

Conclusions: Turnover was positively associated with the probability of an infection control citation. Staff turnover should be considered an important factor related to the spread of infections within nursing homes.

Keywords: COVID19; employee turnover; health workforce; infection control; long-term care; nursing home.

FIGURE 1

Distribution of nurse turnover and minutes per resident day by nurse type. (A) Turnover. (B) Minutes per resident day. *The turnover rate is defined as the percent of staff hours in the 2 weeks prior to the inspection survey that was provided by new staff [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 2

Average marginal effects of predictors on infection control citation. (A) Coefficients for nurse turnover and nurse minutes per day from regression model with facility fixed effects. (B) Coefficients for nurse turnover and nurse minutes per day from regression model with heterogeneous effects by nurse type and facility fixed effects. (C) Predictive margins for nurse turnover from regression model with facility fixed effects. (D) Predictive margins for nurse minutes per resident day from regression model with facility fixed effects. Percentage point (pp); minutes (min); registered nurse (RN), licensed practical nurse (LPN), certified nurse assistant (CNA); percentile (p); standard deviation (SD). Panels (A), (C), and (D) were created using linear regression models with facility‐level fixed effects where the outcome was a dichotomous variable indicating presence or lack of infection control citation with independent variables nurse turnover and nurse minutes per resident day. Panel (B) was created using linear regression models with facility‐level fixed effects where the outcome was a dichotomous variable indicating presence or lack of infection control citation with independent variables RN, LPN, CNA turnover and RN, LPN, CNA minutes per resident day. The number of observations in the regression was 30,536. The turnover rate is defined as the percent of staff hours in the 2 weeks prior to the inspection survey that was provided by new staff [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 3

Average marginal effects for scope of infection control citation. (A) Average marginal effects for turnover and nurse minutes per resident day from an ordered logit model with facility fixed effects. (B) Predicted distribution of citation scope from an ordered logit model with facility fixed effects. Average marginal effect (AME); minute (min); percentage point (pp); percentile (p); standard deviation (SD). Panel (A) presents average marginal effects. Panel (B) visualizes the unconditional average marginal effects. Models used facility fixed effects with a four‐level outcome of the scope of the citation (no citation, isolated, pattern, widespread), with nurse turnover and nurse minutes per resident day as independent variables. The number of observations used in the regression was 19,749. This is smaller than the sample used in the linear probability model because the inclusion of facility fixed effects in ordered logit model necessitates that the estimates are identified off of the facilities that experienced the change or where a citation was present (e.g., if a facility had no citations for the sample period they do not contribute information to the estimation). The turnover rate is defined as the percent of staff hours in the 2 weeks prior to the inspection survey that was provided by new staff [Color figure can be viewed at wileyonlinelibrary.com]