Original Study| Volume 21, ISSUE 9, P1254-1259.e2, September 2020

Leadership, Staff Empowerment, and the Retention of Nursing Assistants: Findings From a Survey of U.S. Nursing Homes



      We examined the relationship between nursing assistant (NA) retention and a measure capturing nursing home leadership and staff empowerment.


      Cross-sectional study using nationally representative survey data.

      Setting and Participants

      Data from the Nursing Home Culture Change 2016-2017 Survey with nursing home administrator respondents (N = 1386) were merged with facility-level indicators.


      The leadership and staff empowerment practice score is an index derived from responses to 23 survey items and categorized as low, medium, and high. Multinomial logistic regression weighted for sample design and to address culture-change selection bias identified factors associated with 4 categories of 1-year NA retention: 0% to 50%, 51% to 75%, 76% to 90%, and 91% to 100%.


      In an adjusted model, greater leadership and staff empowerment levels were consistently associated with high (76%-90% and 91%-100%) relative to low (0%-50%) NA retention. Occupancy rate, chain status, licensed practical nurse and certified nursing assistant hours per day per resident, nursing home administrator turnover, and the presence of a union were also significantly associated with higher categories of retention (vs low retention).

      Conclusions and Implications

      Modifiable leadership and staff empowerment practices are associated with NA retention. Associations are most significant when examining the highest practice scores and retention categories. Nursing homes seeking to improve NA retention might look to leadership and staff empowerment practice changes common to culture change.


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