IDEAS home Printed from https://ideas.repec.org/a/ucp/amjhec/v4y2018i2p131-163.html
   My bibliography  Save this article

The Impact of Nurse Turnover on Quality of Care and Mortality in Nursing Homes: Evidence from the Great Recession

Author

Listed:
  • Yaa Akosa Antwi

    (Johns Hopkins Carey Business School y.akosa.antwi@jhu.edu Author email: y.akosa.antwi@jhu.edu)

  • John R. Bowblis

    (Department of Economics, Miami University)

Abstract

We estimate the causal effect of nurse turnover on mortality and the quality of nursing home care with a fixed-effect instrumental variable estimation that uses the unemployment rate as an instrument for nursing turnover. We find that ignoring endogeneity leads to a systematic underestimation of the effect of nursing turnover on mortality and quality of care in a sample of California nursing homes. Specifically, a 10 percentage point increase in nurse turnover results in a facility receiving 1.8 additional deficiencies per annual regulatory survey, reflecting a 16.5 percent increase. Not accounting for endogeneity of turnover leads to results that suggest only a 1 percent increase in deficiencies. We also find suggestive evidence that turnover results in lower quality in other dimensions and may increase mortality.

Suggested Citation

  • Yaa Akosa Antwi & John R. Bowblis, 2018. "The Impact of Nurse Turnover on Quality of Care and Mortality in Nursing Homes: Evidence from the Great Recession," American Journal of Health Economics, University of Chicago Press, vol. 4(2), pages 131-163, Spring.
    • Handle: RePEc:ucp:amjhec:v:4:y:2018:i:2:p:131-163
    as

    Download full text from publisher

    File URL: https://www.journals.uchicago.edu/doi/pdf/10.1162/ajhe_a_00096
    Download Restriction: Access to PDF is restricted to subscribers.
    ---><---

    As the access to this document is restricted, you may want to look for a different version below or search for a different version of it.

    Other versions of this item:

    References listed on IDEAS

    as
    1. Bruce Fallick & Charles A. Fleischman & James B. Rebitzer, 2006. "Job-Hopping in Silicon Valley: Some Evidence Concerning the Microfoundations of a High-Technology Cluster," The Review of Economics and Statistics, MIT Press, vol. 88(3), pages 472-481, August.
    2. Ann H. Stevens & Douglas L. Miller & Marianne E. Page & Mateusz Filipski, 2015. "The Best of Times, the Worst of Times: Understanding Pro-cyclical Mortality," American Economic Journal: Economic Policy, American Economic Association, vol. 7(4), pages 279-311, November.
    3. Carol Propper & John Van Reenen, 2010. "Can Pay Regulation Kill? Panel Data Evidence on the Effect of Labor Markets on Hospital Performance," Journal of Political Economy, University of Chicago Press, vol. 118(2), pages 222-273, April.
    4. David Grabowski & John Bowblis & Judith Lucas & Stephen Crystal, 2011. "Labor Prices and the Treatment of Nursing Home Residents with Dementia," International Journal of the Economics of Business, Taylor & Francis Journals, vol. 18(2), pages 273-292.
    5. Munasinghe, Lalith, 2006. "Expectations matter: Job prospects and turnover dynamics," Labour Economics, Elsevier, vol. 13(5), pages 589-609, October.
    6. Reagan A. Baughman & Kristin E. Smith, 2012. "Labor Mobility Of The Direct Care Workforce: Implications For The Provision Of Long‐Term Care," Health Economics, John Wiley & Sons, Ltd., vol. 21(12), pages 1402-1415, December.
    7. Andrews,Donald W. K. & Stock,James H. (ed.), 2005. "Identification and Inference for Econometric Models," Cambridge Books, Cambridge University Press, number 9780521844413, October.
    8. Christopher J. Ruhm, 2000. "Are Recessions Good for Your Health?," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 115(2), pages 617-650.
    9. Cook, Andrew & Gaynor, Martin & Stephens Jr, Melvin & Taylor, Lowell, 2012. "The effect of a hospital nurse staffing mandate on patient health outcomes: Evidence from California's minimum staffing regulation," Journal of Health Economics, Elsevier, vol. 31(2), pages 340-348.
    10. Douglas Staiger & James H. Stock, 1997. "Instrumental Variables Regression with Weak Instruments," Econometrica, Econometric Society, vol. 65(3), pages 557-586, May.
    11. Gertler, Paul J, 1992. "Medicaid and the Cost of Improving Access to Nursing Home Care," The Review of Economics and Statistics, MIT Press, vol. 74(2), pages 338-345, May.
    12. Paul Frijters & Michael A. Shields & Stephen Wheatley Price, 2007. "Investigating the quitting decision of nurses: panel data evidence from the british national health service," Health Economics, John Wiley & Sons, Ltd., vol. 16(1), pages 57-73, January.
    13. Carl M. Campbell III & Kunal S. Kamlani, 1997. "The Reasons for Wage Rigidity: Evidence from a Survey of Firms," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 112(3), pages 759-789.
    14. Rory Eckardt & Bruce C. Skaggs & Mark Youndt, 2014. "Turnover and Knowledge Loss: An Examination of the Differential Impact of Production Manager and Worker Turnover in Service and Manufacturing Firms," Journal of Management Studies, Wiley Blackwell, vol. 51(7), pages 1025-1057, November.
    15. Weiss, Andrew W, 1980. "Job Queues and Layoffs in Labor Markets with Flexible Wages," Journal of Political Economy, University of Chicago Press, vol. 88(3), pages 526-538, June.
    16. Douglas L. Miller & Marianne E. Page & Ann Huff Stevens & Mateusz Filipski, 2009. "Why Are Recessions Good for Your Health?," American Economic Review, American Economic Association, vol. 99(2), pages 122-127, May.
    17. N/A, 2009. "On the Recession," Local Economy, London South Bank University, vol. 24(3), pages 253-253, May.
    18. Jovanovic, Boyan, 1979. "Job Matching and the Theory of Turnover," Journal of Political Economy, University of Chicago Press, vol. 87(5), pages 972-990, October.
    19. Zeynep Ton & Robert S. Huckman, 2008. "Managing the Impact of Employee Turnover on Performance: The Role of Process Conformance," Organization Science, INFORMS, vol. 19(1), pages 56-68, February.
    20. Haizhen Lin, 2014. "Revisiting the relationship between nurse staffing and quality of care in nursing homes: An instrumental variables approach," Working Papers 2014-01, Indiana University, Kelley School of Business, Department of Business Economics and Public Policy.
    21. Lin, Haizhen, 2014. "Revisiting the relationship between nurse staffing and quality of care in nursing homes: An instrumental variables approach," Journal of Health Economics, Elsevier, vol. 37(C), pages 13-24.
    22. Charlene Harrington & David Zimmerman & Sarita L. Karon & James Robinson & Patricia Beutel, 2000. "Nursing Home Staffing and Its Relationship to Deficiencies," The Journals of Gerontology: Series B, The Gerontological Society of America, vol. 55(5), pages 278-287.
    23. John Bowblis & Judith Lucas, 2012. "The impact of state regulations on nursing home care practices," Journal of Regulatory Economics, Springer, vol. 42(1), pages 52-72, August.
    24. Alexandre Mas, 2006. "Pay, Reference Points, and Police Performance," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 121(3), pages 783-821.
    25. Grabowski, David C., 2001. "Medicaid reimbursement and the quality of nursing home care," Journal of Health Economics, Elsevier, vol. 20(4), pages 549-569, July.
    26. Cawley, John & Grabowski, David C. & Hirth, Richard A., 2006. "Factor substitution in nursing homes," Journal of Health Economics, Elsevier, vol. 25(2), pages 234-247, March.
    27. Grabowski, David C. & Feng, Zhanlian & Hirth, Richard & Rahman, Momotazur & Mor, Vincent, 2013. "Effect of nursing home ownership on the quality of post-acute care: An instrumental variables approach," Journal of Health Economics, Elsevier, vol. 32(1), pages 12-21.
    28. Jordan D. Matsudaira, 2014. "Government Regulation and the Quality of Healthcare: Evidence from Minimum Staffing Legislation for Nursing Homes," Journal of Human Resources, University of Wisconsin Press, vol. 49(1), pages 32-72.
    29. Shapiro, Carl & Stiglitz, Joseph E, 1984. "Equilibrium Unemployment as a Worker Discipline Device," American Economic Review, American Economic Association, vol. 74(3), pages 433-444, June.
    30. Jennifer Craft Morgan & Janette Dill & Arne L Kalleberg, 2013. "The quality of healthcare jobs: can intrinsic rewards compensate for low extrinsic rewards?," Work, Employment & Society, British Sociological Association, vol. 27(5), pages 802-822, October.
    Full references (including those not matched with items on IDEAS)

    Citations

    Citations are extracted by the CitEc Project, subscribe to its RSS feed for this item.
    as


    Cited by:

    1. R. Tamara Konetzka & Karen B. Lasater & Edward C. Norton & Rachel M. Werner, 2018. "Are Recessions Good for Staffing in Nursing Homes?," American Journal of Health Economics, MIT Press, vol. 4(4), pages 411-432, Fall.
    2. Baughman Reagan, 2018. "Employment in Long-Term Care: The Role of Macroeconomic Conditions," The B.E. Journal of Economic Analysis & Policy, De Gruyter, vol. 18(4), pages 1-12, October.
    3. Shishir Shakya & Sriparna Ghosh & Conor Norris, 2022. "Nurse Licensure Compact and Mobility," Journal of Labor Research, Springer, vol. 43(2), pages 260-274, June.
    4. Bar, M.; & Bakx, P.; & Wouterse, B.; & van Doorslaer, Eddy.;, 2022. "Estimating the health value added by nursing homes," Health, Econometrics and Data Group (HEDG) Working Papers 22/12, HEDG, c/o Department of Economics, University of York.
    5. Ana Soto-Rubio & María del Carmen Giménez-Espert & Vicente Prado-Gascó, 2020. "Effect of Emotional Intelligence and Psychosocial Risks on Burnout, Job Satisfaction, and Nurses’ Health during the COVID-19 Pandemic," IJERPH, MDPI, vol. 17(21), pages 1-14, October.
    6. Xavier Flawinne & Mathieu Lefebvre & Sergio Perelman & Pierre Pestieau & Jérôme Schoenmaeckers, 2023. "Nursing homes and mortality in Europe: Uncertain causality," Health Economics, John Wiley & Sons, Ltd., vol. 32(1), pages 134-154, January.
    7. Martin Hackmann & Joerg Heining & Roman Klimke & Maria Polyakova & Holger Seibert, 2021. "General Equilibrium Effects of Insurance Expansions: Evidence from Long-Term Care Labor Markets," Upjohn Working Papers 21-357, W.E. Upjohn Institute for Employment Research.
    8. Juan Mao & Baolei Qi, 2017. "Determinants and Economic Consequences of Signing Auditor Turnover: A Large-Scale Study from China REPORT," Working Papers 0138acc, College of Business, University of Texas at San Antonio.
    9. Thomas Rapp & Jonathan Sicsic & Neda Tavassoli & Yves Rolland, 2023. "Do not PIMP my nursing home ride! The impact of Potentially Inappropriate Medications Prescribing on residents’ emergency care use," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 24(7), pages 1085-1100, September.
    10. Bär, Marlies & Bakx, Pieter & Wouterse, Bram & van Doorslaer, Eddy, 2022. "Estimating the health value added by nursing homes," Journal of Economic Behavior & Organization, Elsevier, vol. 203(C), pages 1-23.
    11. Mommaerts, Corina & Truskinovsky, Yulya, 2020. "The cyclicality of informal care," Journal of Health Economics, Elsevier, vol. 71(C).
    12. Sean Shenghsiu Huang & John R. Bowblis, 2018. "The principal–agent problem and owner‐managers: An instrumental variables application to nursing home quality," Health Economics, John Wiley & Sons, Ltd., vol. 27(11), pages 1653-1669, November.
    13. Vicente Prado-Gascó & María del Carmen Giménez-Espert & Hans De Witte, 2021. "Job Insecurity in Nursing: A Bibliometric Analysis," IJERPH, MDPI, vol. 18(2), pages 1-13, January.
    14. Drost, Alyssa & Alam, M Injamam & Boamah, Sheila & Kralj, Boris & Costa, Andrew & Sweetman, Arthur, 2023. "Multiple jobholding and part-time work among nurses in long-term care homes compared to other healthcare sectors: Evidence from Ontario," Health Policy, Elsevier, vol. 130(C).
    15. Cécile Martin & Mélina Ramos-Gorand, 2017. "High turnover among nursing staff in private nursing homes for dependent elderly people in France: impact of the local environment and the wage," Economie et Statistique / Economics and Statistics, Institut National de la Statistique et des Etudes Economiques (INSEE), issue 493, pages 49-66.
    16. Castro-Pires, Henrique & Mello, Marco & Moscelli, Giuseppe, 2023. "Foreign Nurses and Hospital Quality: Evidence from Brexit," IZA Discussion Papers 16616, Institute of Labor Economics (IZA).
    17. Johannes Geyer & Peter Haan & Mia Teschner, 2024. "The Impact of Macroeconomic Conditions on Long-Term Care: Evidence on Prices," Discussion Papers of DIW Berlin 2096, DIW Berlin, German Institute for Economic Research.

    Most related items

    These are the items that most often cite the same works as this one and are cited by the same works as this one.
    1. Haizhen Lin, 2014. "Revisiting the relationship between nurse staffing and quality of care in nursing homes: An instrumental variables approach," Working Papers 2014-01, Indiana University, Kelley School of Business, Department of Business Economics and Public Policy.
    2. Lin, Haizhen, 2014. "Revisiting the relationship between nurse staffing and quality of care in nursing homes: An instrumental variables approach," Journal of Health Economics, Elsevier, vol. 37(C), pages 13-24.
    3. Mommaerts, Corina & Truskinovsky, Yulya, 2020. "The cyclicality of informal care," Journal of Health Economics, Elsevier, vol. 71(C).
    4. Carol Propper & John Van Reenen, 2010. "Can Pay Regulation Kill? Panel Data Evidence on the Effect of Labor Markets on Hospital Performance," Journal of Political Economy, University of Chicago Press, vol. 118(2), pages 222-273, April.
    5. Foster, Andrew D. & Lee, Yong Suk, 2015. "Staffing subsidies and the quality of care in nursing homes," Journal of Health Economics, Elsevier, vol. 41(C), pages 133-147.
    6. Atul Gupta & Sabrina T Howell & Constantine Yannelis & Abhinav Gupta, 2021. "Does Private Equity Investment in Healthcare Benefit Patients? Evidence from Nursing Homes," Working Papers 2021-20, Becker Friedman Institute for Research In Economics.
    7. R. Tamara Konetzka & Karen B. Lasater & Edward C. Norton & Rachel M. Werner, 2018. "Are Recessions Good for Staffing in Nursing Homes?," American Journal of Health Economics, University of Chicago Press, vol. 4(4), pages 411-432, Fall.
    8. Furtado, Delia & Ortega, Francesc, 2020. "Does Immigration Improve Quality of Care in Nursing Homes?," IZA Discussion Papers 13552, Institute of Labor Economics (IZA).
    9. Matthew C. Harris & Yinan Liu & Ian McCarthy, 2019. "Capacity Constraints and the Provision of Public Services: The Case of Workers in Public Health Clinics," NBER Working Papers 25706, National Bureau of Economic Research, Inc.
    10. Susan Feng Lu & Lauren Xiaoyuan Lu, 2017. "Do Mandatory Overtime Laws Improve Quality? Staffing Decisions and Operational Flexibility of Nursing Homes," Management Science, INFORMS, vol. 63(11), pages 3566-3585, November.
    11. John R. Bowblis & Austin C. Smith, 2021. "Occupational Licensing of Social Services and Nursing Home Quality: A Regression Discontinuity Approach," ILR Review, Cornell University, ILR School, vol. 74(1), pages 199-223, January.
    12. John R. Bowblis & Andrew Ghattas, 2017. "The Impact of Minimum Quality Standard Regulations on Nursing Home Staffing, Quality, and Exit Decisions," Review of Industrial Organization, Springer;The Industrial Organization Society, vol. 50(1), pages 43-68, February.
    13. Lídia Farré & Francesco Fasani & Hannes Mueller, 2018. "Feeling useless: the effect of unemployment on mental health in the Great Recession," IZA Journal of Labor Economics, Springer;Forschungsinstitut zur Zukunft der Arbeit GmbH (IZA), vol. 7(1), pages 1-34, December.
    14. Gabriel A. Facchini Palma, 2020. "Low Staffing in the Maternity Ward: Keep Calm and Call the Surgeon," Working Papers wpdea2009, Department of Applied Economics at Universitat Autonoma of Barcelona.
    15. Halliday, Timothy J., 2014. "Unemployment and mortality: Evidence from the PSID," Social Science & Medicine, Elsevier, vol. 113(C), pages 15-22.
    16. Ruhm, Christopher J., 2015. "Recessions, healthy no more?," Journal of Health Economics, Elsevier, vol. 42(C), pages 17-28.
    17. McInerney, Melissa & Mellor, Jennifer M., 2012. "Recessions and seniors’ health, health behaviors, and healthcare use: Analysis of the Medicare Current Beneficiary Survey," Journal of Health Economics, Elsevier, vol. 31(5), pages 744-751.
    18. Norton, E.C., 2016. "Health and Long-Term Care," Handbook of the Economics of Population Aging, in: Piggott, John & Woodland, Alan (ed.), Handbook of the Economics of Population Aging, edition 1, volume 1, chapter 0, pages 951-989, Elsevier.
    19. Sean Shenghsiu Huang & John R. Bowblis, 2018. "The principal–agent problem and owner‐managers: An instrumental variables application to nursing home quality," Health Economics, John Wiley & Sons, Ltd., vol. 27(11), pages 1653-1669, November.
    20. Bär, Marlies & Bakx, Pieter & Wouterse, Bram & van Doorslaer, Eddy, 2022. "Estimating the health value added by nursing homes," Journal of Economic Behavior & Organization, Elsevier, vol. 203(C), pages 1-23.

    More about this item

    Keywords

    employee turnover; unemployment rate; quality of care; nursing home;
    All these keywords.

    JEL classification:

    • E24 - Macroeconomics and Monetary Economics - - Consumption, Saving, Production, Employment, and Investment - - - Employment; Unemployment; Wages; Intergenerational Income Distribution; Aggregate Human Capital; Aggregate Labor Productivity
    • I11 - Health, Education, and Welfare - - Health - - - Analysis of Health Care Markets
    • J21 - Labor and Demographic Economics - - Demand and Supply of Labor - - - Labor Force and Employment, Size, and Structure

    Statistics

    Access and download statistics

    Corrections

    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:ucp:amjhec:v:4:y:2018:i:2:p:131-163. See general information about how to correct material in RePEc.

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If CitEc recognized a bibliographic reference but did not link an item in RePEc to it, you can help with this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: Journals Division (email available below). General contact details of provider: https://www.journals.uchicago.edu/AJHE .

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service. RePEc uses bibliographic data supplied by the respective publishers.