Turnover among Certified Nursing Assistants (CNAs) in nursing homes is an enormous problem, with estimates of annual turnover ranging from 42 percent to an astounding 86 percent. CNA turnover has been linked to diminished quality of care, resident behavioral problems and poor end-of-life quality indicators. Turnover is also expensive for nursing homes; replacing just one CNA is estimated to cost $2,200. No wonder there is great interest in improving retention rates.


A recent University of Washington and Brown University study demonstrated link between improved retention and empowerment-focused staffing practices, a promising approach that has been adopted by at least one Labor Management Project (LMP) partner. Staff empowerment generally encompasses providing CNAs with training opportunities, valuing their work and giving them the opportunity to be involved in care planning and decision-making.

In this national study, researchers analyzed survey data from over 2,000 nursing home administrators about culture change implementation. Each nursing home received a “staff empowerment score” based on the administrator’s answers to seven survey items. Nursing homes that scored high on staff empowerment were 64 percent more likely to have higher CNA retention than homes that scored low on empowerment.


Nearly all surveyed administrators reported that CNAs are routinely made aware of resident care plan changes, an empowerment practice. Almost half reported that CNAs in their facility “often” or “always” take part in quality improvement teams, an approach that meaningfully involves CNAs in resident care and acknowledges their intimate understanding of resident needs. Study authors recommended that homes that do not engage in these practices consider doing so.


The study revealed areas where most nursing homes could better empower their CNA workforce. For example, less than a third of surveyed administrators reported that their facility “often” or “always” cross-trains CNAs or provides them with rewards (e.g., bonuses, raises) for extra training or education, two additional empowerment practices that have been shown to be effective. This might be an issue for our union partners.


ArchCare, the continuing care community of the Archdiocese of York, has invested in training CNAs in process improvement strategies as a way of empowering them to contribute to improving resident care. “CNAs and other direct care staff throughout the ArchCare system are encouraged to be creative and make recommendations about how we can improve patient care,” said Senior Vice President and Chief Experience Officer Hugo Pizzaro. “With support from the Labor Management Project, we have trained direct care staff in Lean-Six Sigma process improvement techniques, so they can more fully participate in QAPI (Quality Assurance & Performance Improvement) projects.”


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