CNA Turnover Costs: Pain Points for Skilled Nursing Facilities

The cost of certified nursing assistant (CNA) turnover in skilled nursing facilities is detrimental to an organization’s financial health. Managers understand this is a significant pain point that negatively affects the bottom line. But what are the most critical factors leading to overall turnover costs? Can you implement solutions to prevent turnover or mitigate its effects?

Potential solutions will be most effective if nursing supervisors and managers understand the issue from a holistic perspective. If you don’t know why CNAs are quitting, it’s hard to make effective changes or create protocols that ensure accountability.

For skilled nursing facilities (SNFs), 2020 was an excruciating year in terms of nurse aide turnover. Perhaps understanding how and why CNA turnover affects SNFs can help us create opportunities for lasting change.

Significant pain points of CNA turnover costs include time and money spent onboarding and low-performance penalty fees incurred. In terms of remedies, potential solutions include CNA empowerment and preventing clinician burnout.

Here are some of the issues surrounding CNA turnover costs in SNFs.

Recruiting and Onboarding Is Expensive

To replace a CNA, an organization could spend between $3,000 and $6,000 on indirect costs such as overtime and on direct costs such as recruiting and onboarding, says Vince Baiera, Principal of Post-Acute Care at Relias.

In addition, during the recruiting and onboarding process for new hires, some CNAs may agree to pick up overtime hours, only to burn themselves out with heavy patient loads. The added stress can potentially lead to job dissatisfaction and increase the chance of even more turnover down the line.

CNA On-the-Job Training Is Important

Studies show that better-trained CNAs lead to lower turnover rates. Yet many newly hired CNAs walk into a new facility and receive little or no on-the-job training. Skimping on training can lead to miscommunication by the institution concerning employment expectations. In addition, it may lead to CNAs feeling frustrated and neglected.

One solution to consider might be to promote senior CNA staffers into training roles. When CNAs teach new hires, formal onboarding per the institution’s guidelines occurs. New hires have a go-to person for questions as they take on their patient assignments. Also, institutions ensure that all staff members have a clear understanding of their job roles to eliminate miscommunication from both sides.

Staffing Levels Too Low

Nursing homes are required to have certain staffing levels to meet adequate safety and quality patient care. However, most nursing homes in the U.S. are not meeting recommended staffing levels.

The 2020 pandemic was a tipping point for the already exceedingly low CNA staffing levels in nursing homes. An even higher CNA turnover epidemic resulted as some staff feared for their safety and those left behind struggled to keep up with patient loads.

Recognizing Staff Burnout

CNA burnout is a huge cause of CNA turnover. It can also create a revolving door for even more turnover down the line. Therefore, not addressing staff burnout issues can become a money pit for institutions.

There are many reasons for CNA burnout, but two of the most important are moral injury and emotional exhaustion.

Moral Injury is a term more recently used in healthcare to describe a healthcare provider’s guilt and shame for not providing the care they know their patients need. When CNAs manage too many patients at once, the guilt of not doing enough can lead to high stress, anxiety, and even depression.

In addition, many caregivers also experience grief and emotional exhaustion due to working with sick and dying patients. It is not uncommon for staff members to form friendships with patients who eventually pass away.

Some managers may not be aware these issues are occurring. For this reason, it is imperative to ask staff how they are feeling about their workloads. In this case, listening and addressing staff concerns may be the difference between turnover and adequate staffing.

Avoiding Penalties, Maximizing Payments

Managers are aware that Medicare and Medicaid reward SNFs with a Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program. Through this program, SNFs are rewarded with incentive payments based on the quality of care they give their patients. The Centers for Medicare and Medicaid Services (CMS) evaluation measures are:

  • Performance of hospital readmission measures
  • Improvement and achievement scores
  • Monthly feedback about performance

One could argue that a healthy CNA culture would result in higher incentive payments, leading to a higher level of patient care. Conversely, CNA turnover could easily result in a facility being penalized for not reaching VBP goals due to low performance. As pillars of nursing care in SNFs, CNAs ensure high achievement scores. But CNA turnover, which is often preventable, can make this incredibly difficult.

Staff Empowerment

Institutions with low staff empowerment also have lower retention rates. But facilities that empower CNAs have the opposite result.

A 2016 study of earlier survey data from 2,034 nursing home administrators found that facilities with high CNA empowerment scores had a 64% greater likelihood for higher retention than those that didn’t.

The questionnaire asked the administrators questions such as:

  • Do others besides administrators plan social gatherings?
  • Do CNAs take part in improvement teams?
  • Does your nursing home give bonuses or rewards for higher education or training?
  • Do CNAs know when a resident’s care is changed?

Those who had more “yes” answers to the questionnaire also had higher retention scores. Empowering CNAs with decision-making that involves patient care, rewarding those who learn, and giving CNAs a voice to help improve workplace culture all lower turnover rates.

Negative Workplace Cultures

Reducing staff incivility and increasing respect among healthcare providers is an essential step for staff retention. A 2017 study from Sage Journals on toxic work environments found that CNAs who were “bullied” in the workplace had higher patient and staff safety issues. In addition, toxic workplaces negatively affected the quality of caregiving to residents at the facility.

When an institution has this type of toxic culture among CNA staff, it leads to turnover, burnout, and potentially CMS penalties due to low-performance scores. Enforcing a positive workplace culture and encouraging teamwork and civility among CNAs is a win-win.

In other words, what is good for the institution is also good for the CNA. Prioritizing the role of the CNA not only improves patient care but fosters the financial growth of the institution and eliminates the revolving door of CNA turnover costs.

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Sarah Jividen, RN, BSN, is a trained neuro/trauma and emergency room nurse turned freelance healthcare writer. As a journalism major, she combined her love for writing with her passion for high-level patient care. Jividen is the creator of Health Writing Solutions, LLC, specializing in writing about healthcare topics, including health journalism, education, and evidence-based health and wellness trends. She lives in Northern California with her husband and two children.

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