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DURHAM, N.C. -- The chronic staffing turnover common to many of the nursing homes that serve more than 1.4 million elderly persons in the United States is lower at nursing homes with stable nursing leadership, according to a new study by researchers from the Duke University School of Nursing.

The research published in the June 2004 issue of The Gerontologist says nursing homes with good communication, a merit-based work environment and adequate staffing have an edge in retaining nurses at a time when many facilities are competing to fill these positions.

"Turnover rates for staff in nursing homes can be as high as 200 percent in a year," said registered nurse Ruth Anderson, Ph.D., lead author and associate professor with the Duke University School of Nursing. "New nurses have to be trained. Patients have to get to know them and there is less time for the nursing staff to bond with the patients. Nurses need their managers to create the right work environment so they can feel comfortable at the facility and want to stay. Until we do that, we are going to continue to have this instability that is such a problem in the industry."

The study surveyed the staff of 164 nursing homes in Texas. Staff included nursing home administrators, directors of nursing, registered nurses, licensed vocational nurses (also known as licensed practical nurses) and certified nursing assistants.

The researchers found lower turnover rates for registered nurses and licensed vocational nurses directly related to a longer tenure for the director of nursing. For each year the director of nursing remained in her position, RN turnover decreased by 16 percent and LVN turnover decreased by 11 percent. The more time the director of nursing was on staff, the more stable the nurses perceived their work environment.

"Having a good director of nursing that the RN's can work with, can bounce ideas off, is very critical," said Anderson. "If a director of nursing leaves or is fired, that relationship is broken and has to be rebuilt. Sometimes the nurses will leave the nursing home and follow the director of nursing when she is hired somewhere else. It can cause a major staffing shake-up."

A stable work environment was also critical for nursing assistants, for whom a significant factor in reducing turnover was the amount of time they were allowed to spend with each resident.

"If they don't have the time to spend that extra minute with the residents, they feel like they might be cheating the resident," said Anderson. "They're always rushing in and out of the room. That contributes to the high turnover."

The researchers said another important factor in promoting stability is the number of registered nurses on staff. Registered nurses want other nurses with which to collaborate, and nursing assistants need the security of having access to the clinical expertise of the registered nurses.

"Nurses are leaving because they don't feel like they have the support they need to take care of their patients. They also need to know that their managers hear their concerns, so communication is key," said Kirsten Corazzini, Ph.D., assistant professor, Duke University School of Nursing. "Clear expectations from management are important, too. Nurses need to know what is expected of them, and when they are able to reach those goals, they need to be rewarded for that."

The researchers stress that nursing home managers who seek to retain their nurses need to give their directors of nursing a chance to learn from mistakes, build a stable nursing staff and create a positive work environment.

"In many nursing homes, if something happens, blame often lands squarely on the shoulders of the director of nursing," said Anderson. "Many times she is fired. Unfortunately, the lessons learned from those mistakes are taken with that director of nursing when she goes somewhere else. Directors of nursing need to be given the chance to learn and grow in their jobs. If they can do that, the entire facility is a more stable and productive place."

The survey contained closed-ended questions about the employees' social and demographic backgrounds, and their perceptions of management practices at their nursing home. Information on wage competition, case mix, ownership, size, occupancy and turnover was obtained from Texas Medicaid nursing facility cost reports.

The research was funded by the National Institute of Nursing Research and the Trajectories of Aging and Care Center at Duke University Medical Center. Reuben R. McDaniel, professor in the McCombs School of Business at the University of Texas at Austin, is a co-author on the paper.