Employee Turnover and Customer Satisfaction A Comparison Research Proposal

Excerpt from Research Proposal :

Employee turnover and customer satisfaction: a comparison of rural and urban healthcare facilities

Staff turnover within the long-term care industry continues to increase at a significant rate (Castle, 2003). National averages show the overall turnover rate ranges from 38% to 50% for Licensed Practical Nurses (LPN), registered nurses (RN) and administrators and 66% for Certified Nurses Aides (CNA) (American Health Care Association [AHCA], 2008). Turnover increases cost associated with recruitment and training as well as affects quality of care and customer satisfaction. For example, a turnover rate of 45% among 2.6 million long-term care workers costs about $4.1 billion per year. Furthermore, it can lead to inadequate staffing levels which results in decreased continuity of care (Castle, Degenholtz, & Rosen, 2006; Seavey, 2004; LTCCC, 2008). Dr. Charlene Harrington, a leading researcher in the nursing home field, contends that inadequate staffing levels are the primary reason for poor quality of care in nursing homes (LTCCC, 2008). Demographic changes in the U.S. population will affect the national workforce as well as increase the demand for long-term care. A large number of people will leave the workforce, which will increase turnover. At the same time, the aging population will increase the demand for health programs.

Through this study the researcher intends to examine the relationship between employee turnover and customer satisfaction in the healthcare organizations between rural and urban Medicare and Medicaid skilled nursing facilities as measured by turnover rates, family satisfaction scores. This study will utilize quantitative methodology with secondary data that will be taken from the healthcare website.

3. Research philosophy and literature review

Literature indicates that employee turnover affects quality of care as well as employee satisfaction. In addition, it affects quality of life for nursing home residents (Castle, 2001, 2003). Further research in this area is necessary to identify possible alternatives to reducing turnover and thereby improving quality of care in nursing homes. Findings from this study may have implications on methods of employee hiring, retention, patient care indices, and financial impact on facilities.

Moreover, studies show that approximately 30 million individuals age 65 and older will require some type of long-term care services during their lifetime (National Clearinghouse for Long-Term Care, n.d.). The U.S. Department of Health and Human Services estimates that people who reach age 65 will likely have a 40% chance of entering a nursing home. About 10% of the people who enter a nursing home will stay there five years or more (U.S. Department of Health And Human Services, 2005). Demographic trends indicate that the need for long-term care will increase while the number of healthcare workers will decline (U.S. Census Bureau, 2005). Consequently, staffing and turnover will become an even greater issue than it is today (Riggs, 2005).

In addition to turnover and staffing, funding long-term care will be a challenge. The nursing home sector could arguably be considered the most difficult industry in which to operate in the modern health care environment. Multiple factors converge to make this a reality, to include Medicare and Medicaid certification, Nursing Home Reform Act, and Nursing Home Quality Initiatives.

A previous study done by the American Health Care Association in 2002, showed that historically the Medicaid program reimburses approximately $4.75 per hour, per patient, for 24-hour of complete patient care. With this low reimbursement, nursing homes have been forced to pay lower wages. Consequently, it has been difficult for them to retain and attract quality caregivers (AHCA, 2003). As a result, turnover in skilled nursing facilities has been a major issue. Besides the impact on quality of care, there are other costs associated factors for low employee retention. Direct costs include separation, vacancy, replacement, training, and orientation, and increased worker injuries. Indirect costs include lost productivity, reduced service quality, lost client revenue and/or reimbursement, lost clients to other facilities due to deterioration in facility image, and deterioration in organization culture and employee morale that adversely affects quality of care. Employee retention in long-term care is a major issue, especially in the days ahead due to baby boomers and the current economic recession.

In addition to affecting quality of care, turnover is inherently costly. One estimate of the price paid by government payers for high employee turnover in long-term care is roughly $2.5 billion nationwide (My Daily Record, 2005). In addition to the financial considerations, high turnover rates among nursing personnel have an impact on the remaining workforce in an organization and on the residents who receive care in that organization. Consequences of turnover relates to the smoothness and continuity of organizational operations, employee morale, and the difficulty of replacing the departed employee, and it severely impairs the ability of any health care organization to effectively streamline the delivery of health care (Seavey, 2004).

A 2006 study by Castle et al. showed that RN and CNA staffing levels could predict staff turnover. The study suggested that because of the effects of employee turnover, organizations are concerned about monitoring turnover, determining the variables that influence it, and managing turnover behavior.

4. Research objectives and research questions:

As stated above the purpose of this study is to examine the effects of employee turnover on quality of care in Medicare and Medicaid certified skilled nursing facilities in the state of ____ as measured by percentage of compliance with state and federal regulations. The current study will also examine the effects of employee retention on customer satisfaction in skilled nursing facilities. Finally, it will examine to what extent employee turnover and customer satisfaction differ in urban and rural area skilled nursing facilities in the state of

Given the objective of the study, the following are the research questions that will be addressed;

1. To what does employee turnover affect the quality of care in long-term care facilities?

2. To what extent does employee turnover affect customer satisfaction in long-term care facilities?

3. To what extent does employee turnover and customer satisfaction differ in urban and rural areas of their service?

5. Research design & Research Philosophy

The research paradigm associated with this study is based on correlational, theory verification, causal comparative and deterministic model classified as positivist / post positivist quantitative methodology

This study will use a quantitative design to examine the impact of turnover on quality of care and customer satisfaction in ____ skilled nursing facilities located in the state of ____. The research design for this study is a causal-comparative, non-experimental, nonrandom, quantitative design to study the effects of employee turnover on quality of care indicators and customer satisfaction in ____ skilled nursing facilities.

Data Collection Procedures

The Department of Health compiles data collected by state inspectors during the survey process and entered into a government database. Using information from the Department of Health website, a database will be complied using data on percentage of compliance with state and federal regulations, customer satisfaction, occupancy rate, utilization, LPN/RN hours per diem, case mix, and turnover rates. Furthermore, the annual turnover rates for each facility, as reported by the company, will be accumulated in a database. All data will be collected in the aggregate to ensure facility privacy and confidentially of protected health information. Data State surveyors collect the data that is included on the website when they inspect facilities every nine to 15 months. In addition, skilled facilities submit MDS assessments periodically to the state and federal government. The state survey data are collected annually when the facilities receive the annual certification inspection. Furthermore, the MDS assessments are submitted periodically through the duration of the residents' stay in the facility to monitor quality of care.


The unit of analysis is Medicare and Medicaid certified skilled nursing facilities in the state of ____. The sample comprised 102 Medicare and Medicaid certified skilled nursing facilities. These facilities were selected because they meet the size and demographics needed for the proposed quantitative analysis. The methodology and analysis could be adapted to understand the compliance and resident care in all other states because the sample mirrors the characteristics of the entire population. A comprehensive sampling plan will be developed to help ensure an accurate representation in the sample. In addition, the size of the sample will be based on the type of data analysis to be used, the purpose of the study, population size and the characteristics of the population. Other criteria specified to determine the appropriate sample size include the level of precision, the level of confidence or risk, and the degree of variability in the attributes being measured (Neuman, 2006).

A database will be developed consisting of an identifying number for each facility along with the annualized percentage rate of turnover for each facility as reported to the state of ____ for the period January 1, 2011 through December 31, 2011. In addition, the database included facility-level percentages of compliance with federal and state regulations; customer satisfaction scores, utilization, case mix, occupancy, and area (urban vs. rural).


State health inspections, known as surveys, assess the quality of care in skilled nursing facilities through observation, interview, and review of records.…

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