Philadelphia, PA — A new analysis from the University of Pennsylvania’s Leonard Davis Institute of Health Economics finds that strengthening support from mid-level supervisors could sharply reduce turnover among direct care workers in nursing homes — potentially by as much as a quarter.
The findings land as the sector continues to grapple with severe staffing churn. Industry estimates put annual turnover for certified nursing assistants and other frontline staff at 90% to 120%, a costly cycle that drains billions from providers and destabilizes resident care. Researchers say one of the most effective — and often overlooked — levers sits squarely in the middle layer of management.
“Supervisors aren’t just managers; they’re the frontline lifeline for direct care workers drowning in demands,” said Dr. Julie Bynum, who led the study. “Our data shows that empathetic, trained supervisors can cut turnover by a quarter — that’s not optional; it’s essential for sustainable care.”
What ‘next-level’ support looks like
The study examined staffing and retention patterns using CMS Payroll-Based Journal data from 2020 to 2024, along with surveys of 2,500 direct care workers and 800 supervisors across roughly 1,200 facilities. Researchers defined “next-level” support as consistent, practical backing from nurse managers and unit leads — including coaching, schedule flexibility, conflict resolution, and frontline advocacy.
In facilities where supervisors scored high on support measures, voluntary quits among CNAs were 22% lower compared to homes with weaker support. In worker surveys, 68% cited “lack of supervisor empathy and guidance” as a top reason for leaving — ahead of pay (52%) and just behind workload (61%).
Interviews described supervisors as “gatekeepers” who can either amplify stress with rigid rules or ease it by stepping in to solve problems. In understaffed buildings, facilities with less supportive supervisors also had a 35% higher rate of errors in resident care documentation, the analysis found.
Quality and cost implications
High turnover ripples through care quality. Cross-referenced data show homes with frequent staff departures face 15% to 20% higher rates of pressure ulcers, falls, and infections. In contrast, targeted leadership efforts can move the needle. One Pennsylvania operator that launched supervisor-led unit “huddles” cut CNA turnover from 110% to 75% in a year. In a separate Ohio facility, enhanced supervisor training coincided with an 18% improvement in resident satisfaction scores on CMS’ CAHPS survey.
The economics are stark. Replacing a single direct care worker can cost thousands of dollars in recruiting and training. According to industry reports, turnover drains an estimated $7 billion to $10 billion from providers annually. By retaining staff, operators could save $5,000 to $8,000 per worker each year, the Penn team notes.
Training the middle layer
Even so, many facilities don’t invest in developing mid-level leaders. Only about 40% offer structured training for nurse managers and unit supervisors, the study found, often citing budget limits in the post-COVID landscape. Researchers recommend mandatory supervisor training, peer mentoring, and tying performance evaluations to retention outcomes. They also propose a “supervisor support index” that regulators could integrate into quality ratings over time.
Advocates across the sector say the approach is overdue. “Facilities ignoring supervisor support are setting themselves up for failure — we’ve seen 30% retention boosts in members piloting these programs,” said Dana Ritchie, a workforce leader with a national provider group. Robyn Grant of the National Consumer Voice added, “Families see the human cost: under-supported staff means under-cared-for loved ones. This study validates what we’ve heard for years — fix the middle layer, or the whole system crumbles.”
Regulators are watching. CMS Administrator Chiquita Brooks-LaSure said in a recent HHS briefing that, “While federal minimums evolve, voluntary innovations like supervisor training align with our quality goals under the 2025 Nursing Home Improvement Rule.” Federal staffing mandates have stalled amid legal challenges, prompting interest in voluntary strategies that still move quality metrics.
The road ahead
The Penn team urges operators to pilot supervisor-focused interventions ahead of the next CMS rulemaking cycle expected in 2026. Without broader adoption, the long-term care workforce gap — projected by federal officials to top 150,000 caregivers by 2030 — could worsen.
For now, the message is clear: Pay and benefits remain vital, but they aren’t the whole story. Day-to-day leadership — the person who builds the schedule, answers the late-night call, and helps resolve a tough family meeting — may be the most immediate and scalable tool nursing homes have to keep experienced staff at the bedside.
