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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
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    Cited by:

    1. 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.
    2. Erkmen G. Aslim & Shin‐Yi Chou & Kuhelika De, 2024. "Business cycles and healthcare employment," Health Economics, John Wiley & Sons, Ltd., vol. 33(9), pages 2123-2161, September.
    3. 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.
    4. 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.
    5. 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.
    6. 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.
    7. 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.
    8. Laliotis, Ioannis, 2025. "Foreign doctors and hospital quality: Evidence from the English NHS," Labour Economics, Elsevier, vol. 94(C).
    9. 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.
    10. 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).
    11. Bergschneider, Henrik & Heger, Dörte, 2025. "The effect of staffing on objective quality of nursing home care," Ruhr Economic Papers 1144, RWI - Leibniz-Institut für Wirtschaftsforschung, Ruhr-University Bochum, TU Dortmund University, University of Duisburg-Essen.
    12. Shishir Shakya & Sriparna Ghosh & Conor Norris, 2022. "Nurse Licensure Compact and Mobility," Journal of Labor Research, Springer, vol. 43(2), pages 260-274, June.
    13. 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.
    14. 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.
    15. Laliotis, Ioannis, 2025. "Foreign doctors and hospital quality: Evidence from the English NHS," Labour Economics, Elsevier, vol. 94(C).
    16. Bolt, Ester Ellen Trees & Ali, Manhal & Winterton, Jonathan, 2025. "Why nurses quit: Job demands, leadership and voluntary nurse turnover in adult care in the Netherlands," Social Science & Medicine, Elsevier, vol. 365(C).
    17. repec:tsa:wpaper:0138acc is not listed on IDEAS
    18. Mommaerts, Corina & Truskinovsky, Yulya, 2020. "The cyclicality of informal care," Journal of Health Economics, Elsevier, vol. 71(C).
    19. 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.
    20. 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.
    21. 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).
    22. Geyer, Johannes & Haan, Peter & Teschner, Mia, 2024. "The Impact of Macroeconomic Conditions on Long-Term Care: Evidence on Prices," IZA Discussion Papers 17197, Institute of Labor Economics (IZA).

    More about this item

    Keywords

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    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

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