Navigating High Staff Turnover: How Organizational Hierarchy Shaped Assisted Living Facility Employees’ Emotional Responses During the COVID-19 Pandemic

Abstract

Assisted living facility and nursing home staff faced high virus exposure, long hours, and limited resources while caring for vulnerable residents during the COVID-19 pandemic. This led to a turnover crisis, as many long-term care facility employees left due to burnout, safety concerns, and emotional exhaustion. Framed within emotional labor theory and social structural theories of emotions, this study examines the emotional responses of frontline and managerial staff in assisted living facilities (ALFs) during the COVID-19 pandemic, focusing on the impact of high turnover rates. Based on qualitative interview data from semistructured Zoom and in-person interviews with 29 employees at “Harmony House” in Oregon, this study highlights the hierarchical nature of emotional experiences in the workplace among frontline workers, middle management staff, and administrators in ALFs, shaped by high turnover rates during the pandemic. The findings also show that ALF employees attributed turnover to different factors based on their organizational roles. Whereas administrators often attributed turnover to the pandemic or generational traits, frontline and middle management staff emphasized persistent issues, such as low pay, understaffing, and safety risks. These divergent perspectives showcase how institutional hierarchies shape emotional understandings of workplace challenges, advancing the literature on emotional labor and organizational dynamics in long-term care.

The COVID-19 pandemic placed unprecedented pressure on health care systems globally, with long-term care facilities, such as nursing homes and assisted living facilities (ALFs), emerging as particularly vulnerable environments due to both the rapid spread of the virus in the facilities and the immense emotional and physical demands placed on their workforce (Haslam-Larmer et al. 2023; Palacios-Ceña et al. 2021; Titley et al. 2023). Workers in these facilities faced high exposure to the virus, often working long hours with insufficient resources, all while managing the emotional toll of caring for residents at high risk for severe illness and death. These conditions led to a crisis of turnover because many staff members left their positions due to burnout, safety concerns, and emotional fatigue. Turnover has long been a significant challenge in long-term care settings, but it reached an unprecedented high during the pandemic in the United States. In 2021, the staff turnover rate in U.S. nursing homes reached 53 percent, twice as high as the rate in hospitals (Bergman 2023). Research on health care workers during the pandemic has consistently shown a strong link between burnout and turnover as the emotional and physical demands of the job became overwhelming (Frogner and Dill 2022; Mercado et al. 2022; Tabur et al. 2022). The high turnover rates during the pandemic undoubtedly increased the workload for remaining employees; however, the consequences of high turnover rates to the employees still working in the organizations are rarely studied. Even fewer studies have taken a case-study approach that focuses on one facility to provide a more in-depth examination of the divergent responses and strategies ALF employees adopted according to their professional status in the organizational hierarchy during the pandemic.

The emotion-related landscape of long-term care facilities, shaped by the risks, policies, and high turnover rates during the COVID-19 pandemic, provides a compelling context for exploring how employees’ organizational roles influence their emotional experiences. Amid this crisis, staff experienced a wide range of emotions, influenced by their organizational roles and workplace dynamics. This study aims to understand these diverse emotional responses through the lens of emotional labor theory and social structural theories of emotions, drawing on in-depth interviews with 29 employees at an ALF in Oregon. By examining how ALF employees’ organizational roles influence emotional responses and strategies, this research contributes to a deeper understanding of the challenges faced by them during the pandemic. Additionally, the study explores how differing perspectives on high turnover rates, another significant issue during the pandemic, reflect disparities of emotional responses and strategies among frontline workers, middle management staff, and administrators.

Background

How Hierarchies Shape Workplace Emotions

The sociology of emotions provides a foundational framework for understanding how emotions and emotional experiences are shaped by social structures and hierarchies. From a sociological perspective, emotions are not merely individual phenomena but are embedded in social structures (Turner and Stets 2005). One significant area of research within the sociology of emotions examines how workplace regulations and organizational policies influence the emotions employees are expected to display in professional settings. Hochschild’s (1983) seminal work, The Managed Heart: Commercialization of Human Feeling, further developed the concept of emotional labor, describing how professionals such as flight attendants and debt collectors regulate their emotions to conform to workplace expectations. Hochschild argues that “feeling rules” are socially shared norms that dictate what people are supposed to feel, how intensely, and for how long in particular situations. These rules vary by context, culture, and importantly, role or status within an organization or society. Displayed emotions at work are largely shaped by professional and organizational cultures and norms about appropriate displays (Wharton 2009). Over the past two decades, sociologists have increasingly focused on the role and significance of emotional experiences and displays within health care settings, particularly in contexts such as emotional labor among long-term care facilities workers for older adults (Johnson 2023; Rodriquez 2011, 2014), the management of emotions among health care professionals (Byrne et al. 2023; Carminati 2021; Jenkins 2023), interactions between patients and health care providers (Brewer 2023; Erickson and Grove 2008; Larson and Yao 2005; Weilenmann et al. 2018), and health care providers’ responses to organizational stressors (Bolton 2005; Kadović, Mikšić, and Lovrić 2022). These studies have shown the complex nature of emotional dynamics in health care environments, encompassing both interpersonal and systemic challenges.

However, earlier studies on emotion management in health care settings have primarily concentrated on three key areas: the techniques health care providers utilize to manage their emotions or their patients’ emotions in the workplace; the factors that influence or contribute to their emotional experiences, whether positive or negative; and the impact of employees’ emotions in the workplace, whether enhancing their performance or hindering it. Less attention has been given to the hierarchical nature of emotional experiences in the workplace, that is, the way an individual’s position and labor expectations within an organizational hierarchy influences the types and intensity of emotions they are likely to experience. Structural theories of emotions propose that emotional experiences are deeply influenced by an individual’s position within the power and prestige hierarchy (Bericat 2016; Turner and Stets 2006). Specifically, the link between status and emotion has been extensively documented: Individuals occupying higher-status positions are more likely to secure access to and control over resources that facilitate identity verification. This process allows individuals to confirm their social roles and establish their legitimacy within a given context, which is often linked to positive emotional experiences, compared to those in lower-status positions (Burke 2008; Turner and Stets 2006). Turner (2010) advanced the theory of emotional stratification, emphasizing that positive and negative emotions are unequally distributed across society. He explained this dynamic by linking it to social structures operating at the macro, meso, and micro levels, thereby providing a comprehensive framework for understanding emotional inequality. Organizations, as meso-level corporate units, stand as a clear example to explore how emotions are unequally distributed within structured hierarchies. Frontline workers, middle-management staff, and members of the administrative and leadership teams navigate distinct emotional cultures shaped by their positions, interactions, and perceived status within the organizational hierarchy. In the health care settings, frontline workers, such as nurses, nurse assistants, and caregivers, frequently engage in high levels of emotional labor as they provide care under physically and emotionally demanding circumstances (Bolton 2005; Rodriquez 2011, 2014). Although empirical research investigating managers remains limited, it is reasonable to argue that in health care settings, the hierarchy of emotions is deeply embedded within organizational structures, influencing employees’ actions, expectations of their work, and the perceived value of their labor, among other factors.

Examining these patterns is essential to understanding how workplace hierarchies contribute to emotional disparities and the overall emotional climate of an organization in the health care sector. Particularly when these demands were amplified during the COVID-19 pandemic, frontline workers, middle management staff, and administrators faced unprecedented challenges. The intensified stressors during the pandemic have led researchers to explore burnout among health care professionals. Existing research suggests that frontline workers are particularly vulnerable to experiencing burnout and emotional distress due to the demanding nature of their roles (Lai et al. 2020; Santarone, McKenney, and Elkbuli 2020; Smallwood et al. 2021). Studies have consistently shown that these factors combined with limited resources, lack of support, and the repetitive exposure to stressors significantly increase the risk of emotional exhaustion and psychological strain. Furthermore, frontline workers may feel undervalued or unsupported by their organizations, further exacerbating their feelings of stress and contributing to higher rates of burnout (Fisher et al. 2021; Willis et al. 2021).

The Case of Assisted Living Facilities During the Pandemic

Emotional labor in long-term care facilities, such as nursing homes and ALFs, presents a unique and complex challenge due to the nature of caregiving and the vulnerable population being served. Workers in these settings must often manage and regulate their emotions while providing care for residents facing significant physical, emotional, or cognitive challenges, exemplified by James’s (1992:488) formula based on her studies on hospice nurses in the UK: “care = organization + physical labor + emotional labor.” Unlike other health care professions, long-term care facility staff frequently form deep emotional bonds with residents, which can make the emotional labor more intense and personally taxing (Canham et al. 2017; Funk and Outcalt 2020; McGilton and Boscart 2007). According to Rodriquez (2014), in the United States, nursing homes are generally structured with strict vertical hierarchies, where floor staff, responsible for providing direct, face-to-face care to residents, are paid hourly and salaried managers focus primarily on financial and regulatory responsibilities. Building on the unique nature of care work in long-term care facilities and the professional hierarchies within these organizations, Lopez (2006) expanded Hochschild’s (1983) original concept of “emotional labor” by introducing the framework of “organized emotional care” to better understand emotion management in nursing home settings. Lopez (2006) defined organized emotional care as a set of organizational strategies designed to support and foster meaningful relationships between caregivers and residents rather than merely imposing rules to regulate caregivers’ emotions. This perspective shifts the focus from control to facilitation, emphasizing the importance of creating an environment that enables genuine, empathetic interactions in caregiving.

Research Questions

In such stratified workplaces as long-term care facilities, the distinct roles of frontline workers, middle management staff, and administrators give rise to unique emotional dynamics. These dynamics are shaped by the shared goal of delivering compassionate care for residents while balancing operational efficiency. However, the divergent responsibilities and priorities among these groups can also lead to misaligned expectations, communication challenges, and varying emotional experiences. There is limited research that explores the disparities in emotional responses and strategies among frontline workers, middle-management staff, and members of the administrative and leadership teams. Although much attention has been given to the factors driving high turnover and its impacts (Brazier et al. 2023; Chu et al. 2014; Gandhi, Yu, and Grabowski 2021), less is known about the emotional experiences of those who chose to stay within the organization. Framed within emotional labor theory and social structural theories of emotions, this study examines the emotional responses that ALF employees experienced and employed during the COVID-19 pandemic. I analyze qualitative data from 29 in-depth interviews with employees at an ALF in a suburban area of Oregon with the following main research questions in mind: How did high turnover rates impact the emotional responses of employees who chose to remain during the COVID-19 pandemic? Did they exhibit resilience and adaptability, or were they more likely to experience burnout and stress as a result of enduring high demands and witnessing frequent staff changes? Furthermore, were there notable differences or commonalities in these experiences among employees in different professional roles? How did the employees’ organizational roles influence their perceptions of the underlying reasons for high turnover rates?

Data and Method

Data for this study come from in-depth interviews conducted with 29 employees in an ALF in the suburban area of Oregon that I call “Harmony House,” the same data that I analyzed in Yuan (2025). Harmony House was selected for both practical and substantive reasons. First, my personal connections with some staff members facilitated access to the site and helped establish initial trust, which supported a smooth and sustained data collection process. Second, Oregon is widely recognized for its progressive and integrated approach to long-term care. The state’s management of long-term care facilities reflects a dynamic interplay between government regulation, community-based initiatives, and individualized care (Hernandez 2007), making it a highly relevant context for examining organizational dynamics, emotional labor, and workforce challenges in long-term care settings.

Harmony House is a private, for-profit facility with a starting annual rate of approximately $50,000 for residents who are mostly independent and need minimal assistance. Depending on the required level of care, annual costs can increase to as high as $120,000. Nestled amid mountains and gardens, the facility features three distinct units: independent living, assisted living, and memory care. The administrators take pride in the resort-style living experience provided to residents. At full capacity, the facility accommodates around 250 residents and offers an extensive array of amenities, such as a swimming pool, a wellness and fitness center, a movie theater, and a beauty salon, all designed to promote residents’ well-being, comfort, and enjoyment. The majority of residents are upper-middle-class White older adults, with an average age of 85.

In-depth interview data were gathered between July 2021 and May 2022. To recruit participants, the research team initially reached out to key contacts via email, which included both a recruitment flyer and a recruitment email. These key contacts were my personal acquaintances who were employed at Harmony House at the time. Importantly, these contacts did not interact with potential participants, access any study data, or contribute to the research directly. Instead, they distributed the recruitment flyers throughout the facility multiple times. The research team then scheduled interviews with all employees who responded to the flyer. Eligibility criteria required participants to be employed at Harmony House during the interview period. This recruitment strategy resulted in a diverse participant pool, representing a range of occupational roles, including caregivers, administrative assistants, transportation coordinators, medication technicians, registered nurses, team leaders, department directors, and more. Of the 29 interviews conducted, most (n = 18) were held via Zoom, an online conferencing platform. The remaining 11 interviews were conducted in person at the facility in May 2022, ensuring privacy during the sessions. Table 1 provides a summary of the demographic characteristics of all study participants.

Table 1.

Demographic Characteristics of In-Depth Interview Sample (N = 29).

Characteristic	Percentage (n)
Race/ethnicity
White	76 (22)
Non-White	24 (7)
Gender
Male/trans-male	45 (13)
Female	55 (16)
Education
High school	59 (17)
Some college	21 (6)
College	21 (6)
Age range
<22 years	17 (5)
23–29 years	38 (11)
30–40 years	10 (3)
41–50 years	10 (3)
51–65 years	24 (7)
Work status
Full-time	72 (21)
Part-time	28 (8)
Role in the facility
Managerial role
Supervisor/coordinator (middle management)	14 (4)
Department director/leader (administrators)	31 (9)
Frontline worker
Care staff (caregiver, medical technician, etc.)	17 (5)
Other staff (driver, server, housekeeper, etc.)	38 (11)
Years worked in the facility
<1 year	24 (7)
1–3 years	28 (8)
>3 years	48 (14)

Note: To protect participants’ privacy and ensure inclusivity, I combined male and trans-male categories in the data reporting.

It should be recognized that according to the Bureau of Labor Statistics (2023), frontline workers in nursing and residential care facilities, including nursing aides and personal care assistants, earned a median hourly wage of $14.00 to $16.00 in 2022. Middle management personnel, such as supervisors and coordinators, had a median hourly wage of approximately $22.00. In contrast, upper-level managers, such as department directors and executives, in these facilities earned a significantly higher median hourly equivalent of $38.00 to $49.00, underlining a substantial wage disparity across the organizational hierarchy. Based on interview data collected by the author, the hourly wage for a caregiver at Harmony House was approximately $13.50 in 2022.

The interviews lasted between 23 and 65 minutes, with an average duration of 42 minutes. A semistructured interview guide was used, enabling interviewers to probe relevant topics, adjust questions as needed, and tailor the question order to suit the natural flow of the conversation (see Appendix). I utilized MAXQDA, a mixed-methods coding software, to analyze the data. To protect participants’ privacy, all data were de-identified. Using a grounded theory approach (Charmaz 2014), the coding process unfolded in four key stages. First, I created memos based on the interview transcripts, documenting recurring themes during this process. In the second stage, I conducted a more detailed round of coding in MAXQDA to categorize and quantify emerging patterns. During this phase, several coding notes, such as positive emotions, negative emotions, indifference, favorite part of work, least favorite part of work, and most stressful part of the pandemic, were identified. Based on these notes, I developed a preliminary codebook. Subsequently, a comparison was made between the themes identified in the initial memos and the patterns revealed during the second round of coding. Finally, overarching themes were summarized, guided by the frequency of coding notes and the study’s central research questions. The study was initially approved by my former institution, with the approval later transferred to and validated by my current institution.

Results

Before presenting the results, it is important to recognize the inherently emotional nature of working in ALFs like Harmony House. Participants across diverse organizational roles consistently emphasized their deep emotional connections with residents, often comparing them to family members. This sentiment is exemplified by Angela, a member of the administrative and leadership teams, when asked about her relationship with residents:

I sort of see myself as their confidant. I do have a very close emotional bond with them. That being said, I have to learn how to separate myself a little bit within the context of my job because it is so emotionally taxing, and I do deal with some really hard stuff.

Angela’s words reflect the emotional intimacy that can form between staff and residents, even at higher levels of the organizational hierarchy. This emotional closeness highlights the balance between maintaining professional distance and establishing personal connection, especially salient in long-term care environments, where caregiving relationships often resemble familial bonds. Similarly, Greg, a frontline worker, described the residents as “his second family” and emphasized the emotional toll of persistent staff turnover:

We lost about 18 staff members in the span of two or three weeks. . . . We’re taking care of 250 people more than we’re taking care of ourselves. We work where they live—they don’t live where we work.

Greg’s reflection highlights both the scale of the labor involved and the ethical weight that frontline workers internalize. His statement, “We work where they live,” inverts traditional boundaries between personal and professional spaces, capturing the selfless nature of caregiving in assisted living settings. Together, these narratives reveal how emotional attachments intensify the strain of turnover not just by increasing workloads but also by disrupting relationships that form the emotional core of care work.

The results of the study are organized into two subtopics: (1) variations in emotional responses and coping strategies among frontline workers, middle-management staff, and members of the administrative and leadership teams, showcasing how their positions in the organizational hierarchy shaped their responses to the challenges brought on by high turnover rates and (2) divided perceptions of the causes of high turnover rates, highlighting contrasting viewpoints across organizational roles based on their divergent emotional experiences at the individual level. Frontline workers, for example, often attributed turnover to immediate working conditions, such as the feeling of underpaid for the effort they put in, whereas managerial and leadership staff pointed to systemic and external factors, such as the demanding nature of caring for older adults, shifting work ethics among younger generations, and state policies implemented during the pandemic in Oregon.

Divergent Emotional Responses and Coping Strategies

Participants in this study demonstrated distinct emotional responses and coping strategies to high turnover rates among frontline workers, managerial staff, and leadership team members. Although all groups faced challenges exacerbated by the COVID-19 pandemic, their experiences differed in terms of stressors, coping mechanisms, and emotional outcomes.

Frontline Workers: Emotional Exhaustion and Self-Blame

Frontline workers, including direct caregivers, servers, nurse assistants, and medical technicians, described feeling overwhelmed by the increased workload caused by staffing shortages. When asked about the most stressful part of their job during the pandemic, many frontline workers pointed out the significant impact of rapid turnover on their daily working experiences at Harmony House. Many reported working extended hours to cover shifts or taking on additional responsibilities outside their typical duties, often due to frequent callouts from coworkers. This increased workload contributed to significant emotional exhaustion and physical fatigue. For example, Xena, a receptionist, described how a colleague’s repeated absences disrupted the staff schedule and gradually expanded her own responsibilities:

We had a coworker going through some medical things and calling out a lot. I was hired part-time to cover lunches, but I ended up working 7:30 to 3:00, seven days a week, for almost three months. One day, I told my manager, “I can’t do this anymore.” I realized very quickly that my burnout doesn’t help anybody—not me, not the residents, not the facility.

This excerpt illustrates how staff shortages and unpredictability can intensify emotional and physical strain among frontline workers, transforming temporary adjustments into unsustainable routines. Xena’s narrative reflects a growing self-awareness about the cost of overextension, showing how emotional labor intersects with structural instability and the ethical commitments frontline workers feel toward residents. Her experience demonstrates that burnout is not only an individual health issue but also a collective risk, with direct consequences for care quality and organizational cohesion. The stress was particularly intense for medical technicians, direct caregivers, and nurse assistants because these roles often bear the brunt of frontline responsibilities. When a coworker called out, the remaining staff had to shoulder additional duties, leading to increased workloads, time pressure, and emotional strain. The following conversation between the interviewer and Emma, a caregiver, provides a firsthand account of the significant challenges and heightened stress frontline caregivers face when they must compensate for absent coworkers. Emma described the compounding stress when caregivers fail to show up for a shift:

That happened to me once; that was awful. You have to do both jobs. . . . It takes two caregivers just to get residents out of bed. I still had to do my med pass and get their medicine out on time.

Emma’s account illustrates how fragile staffing can be in ALFs, where losing even one worker can cause a chain reaction of problems. She had to take on multiple jobs at once, giving out medications and helping residents physically, which shows how short-staffed workers often have to pick up the extra work when others leave or call out. When asked whether others could be called in to help, she replied:

Yeah, you can, but a lot of people just don’t answer or say no. . . . That’s why I was paid more, because my boss could count on me to show up. They didn’t have to worry about me not showing up and being understaffed.

Here, Emma not only conveys the unpredictability of staff shortages but also frames her reliability as a form of organizational capital. Her willingness to consistently show up for shifts becomes a valued trait, implicitly linked to increased pay and trust from her supervisors. Yet this also shows a troubling pattern where understaffing is treated as normal. Instead of getting real support, dedicated workers are expected to handle the extra pressure and deal with the system’s failures on their own.

Additionally, frontline staff frequently felt undervalued and unsupported, believing that their well-being was not prioritized and that their concerns were largely overlooked. When recounting their experiences during the pandemic, frontline staff frequently described the workplace with phrases such as “a lack of empathy,” “exhausting,” and “frustrating.” These sentiments highlight the emotional toll of navigating a high-stress environment where they often felt unacknowledged and underappreciated. For many, the absence of visible support or efforts to address their challenges during such a critical time left a lasting impression of neglect. Many staff members mentioned that although they were offered online therapy and informational pamphlets about mental health resources, these measures felt insufficient due to the overwhelming demands of their workload. With chronic understaffing, they were often too busy during their shifts to take advantage of these resources and sometimes did not even have time for necessities, such as lunch breaks. Furthermore, some said they were reluctant to use these supports outside of work because they wanted to disconnect from anything work-related when they were off the clock. This shows how hard it is to support their well-being when the demands of the job leave them emotionally and physically drained even during their time off.

Notably, a significant portion of frontline workers, 15 individuals in total, with an average age of 28 and a median age of 24, are young adults navigating the transition to adulthood. Balancing the demands of such a challenging work environment with the broader personal and professional adjustments of this life stage further compounded their stress. For these individuals, the lack of support in the workplace not only affected their job satisfaction but also added to the struggles of navigating this critical period of their development. This struggle is captured in Frank’s reflection as a dining room server:

I experienced burnout from feeling unappreciated, low wages, and being unable to go out. I had to pause school because online classes weren’t effective, which disrupted my goals. And then coming back to a workplace that I really didn’t feel like was going anywhere for me. It was disheartening.

Frank’s experience demonstrates how emotional exhaustion was not limited to direct care workers. His disrupted educational goals and perceived stagnation within the organization exacerbated feelings of disillusionment and burnout. His account illustrates the conflict between personal ambitions and institutional constraints during the pandemic, especially for younger or part-time employees whose career paths were suddenly disrupted.

When discussing the stress caused by understaffing, some respondents tended to blame themselves, citing poor time management as a contributing factor to their struggles. For instance, Hope, a medical technician, explained:

Because we’re so understaffed, I don’t get to spend much time with the residents—which I really wish I could. I’m usually in and out of a room in about three minutes, just handing out medications, making sure they’re swallowed, and then rushing off. I have double the usual number of residents to medicate, so I’m often 30 minutes behind. Ideally, we should have three med techs on a shift, but since COVID-19, we typically only have two. Therefore, the main source of my stress is trying to manage time—some medications, like Parkinson’s meds, have to be given within a strict window, no more than 15 minutes late.

Hope’s comment illustrates how high-stakes time management became a central source of stress. Despite clear structural understaffing, she framed the challenge in terms of individual responsibility, reflecting how workers may internalize systemic pressures as personal failures.

Middle Management Staff: Role Strain and Fear

Middle management staff, including coordinators and supervisors who bridge the gap between frontline workers and upper management focusing on operational efficiency and team supervision, experienced role strain as they tried to balance administrative responsibilities with addressing staff shortages. Many found themselves stepping into operational roles, such as assisting with direct care tasks, which created feelings of inadequacy and guilt. Trinity, a coordinator, said:

The most stressful part is staffing. We’ve struggled to retain caregivers, leading to being short-staffed at times. This makes it difficult to provide residents with the care and attention they deserve. Having enough staff has been the hardest and most frustrating challenge. But a lot of our managers pulled together and came in and helped when needed. Our community came together as one. Everybody in the building wants to just help and be there for the residents.

Trinity’s remarks demonstrate clear evidence of role strain as she and other managers are caught between the demands of administrative oversight and the need to step into direct caregiving roles, a dual burden intensified by ongoing staff shortages. Although the sense of togetherness she describes highlights organizational solidarity, it also suggests blurred role boundaries. This flexibility may offer short-term relief during crises but risks fostering long-term strain and burnout if such expectations persist.

Fear also emerged as a recurring theme, especially among those newly promoted during the pandemic. Victor, who was promoted to a middle management position during the pandemic, expressed feeling a deep sense of fear and anxiety during the early stages of the pandemic, fueled by rumors that if COVID-19 were to spread within Harmony House, employees might be required to stay on site for weeks without returning home. The stress intensified when he transitioned into a managerial role because being on call meant constantly adjusting to unpredictable circumstances. When a day-shift employee became ill, occasionally more than one, the on-call managers were required to step in and cover the shifts, often at the expense of their scheduled duties. The looming threat of working 24-hour shifts became a harsh reality during this period because the on-call manager was ultimately responsible for ensuring coverage when no one else could. Victor’s account highlights the psychological toll of organizational unpredictability and constant availability. The transition into management did not alleviate pressure; instead, it deepened his exposure to crisis response and eroded personal boundaries. The blurring of professional and personal time coupled with the responsibility of ensuring shift coverage pushed him to the brink of burnout.

Administrators: Emotional Management

Administrators faced unique stressors stemming from the need to maintain the facility’s operations and reputation amid constant staffing challenges. They often bore the responsibility of balancing the practical demands of their roles with the emotional impact of supporting both staff and residents during crises. Their emotional responses were predominantly marked by emotional management, enabling them to manage their own stress while providing stability and guidance. When describing the challenges posed by the pandemic at work, Harmony House administrators often concentrated on the positive aspects, such as team resilience and operational achievements, while downplaying or ignoring their own burnout and negative emotions. Although the ability to navigate emotions effectively was essential for fostering resilience and maintaining operational continuity during periods of uncertainty and heightened pressure, this focus on prioritizing the organization’s success often came at the expense of their personal emotional well-being. As Ralph, one of the administrators, reflected,

I didn’t have time to process it [the overwhelming pressure that resulted from juggling multiple job responsibilities, including taking on additional duties to compensate for staff shortages on the floor]. I don’t think any of us have had time to process it . . . there’s a lot of unresolved hurt and frustration . . . from residents passing and not being able to deal with that grief.

Ralph’s narrative reveals the cost of emotion management at the top of the organizational hierarchy. Although middle management staff and frontline workers expressed burnout more openly, administrators were more likely to downplay their own emotional distress, focusing instead on supporting others and maintaining operational continuity.

A few administrators also expressed a deep sense of empathy and regret for not being able to provide more direct support to their staff during the pandemic. For example, Ingrid recalled,

I think the most stressful thing lately has been juggling everything. It’s been hard. We’re doing so much, and it’s exhausting. I think everyone in our industry is mentally drained, which makes it even more challenging to stay upbeat and supportive for my team when they’re struggling—because I’m struggling too, and so is the person down the hall. It’s overwhelming knowing that we can’t fully help each other because we’re still dealing with the ongoing impacts of COVID.

Ingrid’s recognition of mutual struggle suggests that emotional labor in administration also involves suppressing personal distress to preserve organizational morale. These accounts demonstrate how emotional experiences during the pandemic were structured by one’s position in the organizational hierarchy. Frontline staff expressed embodied burnout and grief, often internalizing systemic failures. Middle management described role strain and fear, navigating dual responsibilities under precarious conditions. Administrators focused on emotional containment, highlighting resilience while managing widespread trauma. Together, these findings showcase how emotional labor and stress responses in long-term care are not only personal experiences but also reflections of broader institutional and structural dynamics. Although emotional bonds with residents shaped how employees coped with the challenges of their work, these experiences did not exist in a vacuum. Rather, they were deeply intertwined with employees’ positions within the organizational hierarchy. Building on this, the next section explores how employees from different professional roles, namely, frontline staff, middle management staff, and administrators, interpreted the underlying causes of high turnover. Their perspectives reveal not only role-specific challenges but also the ways in which structural inequalities and organizational expectations shaped their understanding of workplace instability.

Understanding the Causes of High Turnover: Varied Perspectives across Staff Hierarchies

When asked about the reasons behind high turnover, participants from each group offered fundamentally distinct explanations that reflect their organizational position, daily experiences, and perceived responsibilities. These differing accounts provide insight into how emotional labor, workplace structure, and broader political narratives interact to shape interpretations of staffing instability.

Frontline Workers: Working Conditions and Emotional Toll

Frontline workers predominantly attributed turnover to poor working conditions, including low pay, lack of recognition, and excessive workloads. Frank, a dining services employee, described the shift from adequate staffing to “bare-bones” operations:

We had more [coworkers] in the beginning, but then there were wage cutbacks, people getting burned out, and others leaving. . . . They figured out the minimum number of staff needed to do the job, and that’s what they went with.

Frank’s account shows how economic decisions made at the organizational level were experienced by frontline workers as dehumanizing and unsustainable. As staffing levels dropped, workloads intensified, and basic needs, such as meal breaks, became luxuries. His narrative reflects a broader sense of burnout not only from the labor itself but also from the perceived disposability of staff.

The economic pressures of working in a low-wage, high-demand environment were also central to Emma’s experience. She emphasized how the cost of living and rigid schedules made caregiving work increasingly untenable:

Emma:

The cost of living here is really high. . . . Other places, like Taco Bell, were offering more money for less physically demanding work.

Interviewer:

So Harmony House is not able to raise the salary to compete in that same way?

Emma:

No, they’re not. I think they raised it by, maybe $1 or 75 cents a few months ago. But it’s really still not enough to motivate people to stay. A lot of people just want to leave because the 12-hour shifts are just so long, because it’s seven to seven. You’re easily missing out on your kid’s whole day.

Emma’s comparison between caregiving and fast-food work highlights a core contradiction in long-term care employment: Jobs requiring high emotional and physical labor are often underpaid and undervalued. In response to the strain caused by high turnover and frequent callouts, Harmony House adopted a 12-hour shift model, with caregivers working four extended shifts each week followed by three days off. Although this system offers a temporary solution for scheduling gaps, many employees find it physically and emotionally draining, raising concerns about its long-term sustainability. Emma’s remark about 12-hour shifts disrupting family life illustrates how the structure of care work can conflict with personal and familial obligations, pushing many workers to seek less demanding alternatives.

Frontline workers primarily focused on working conditions, such as low wages, excessive workloads, and limited recognition. They expressed frustration over the lack of support and resources necessary to meet the demands of their roles. For many, these day-to-day challenges were seen as the primary reasons why coworkers left their positions, and they felt the effects acutely in their own workloads and emotional well-being. In sum, these frontline perspectives point to a convergence of material and emotional strain. Workers left not merely because of individual dissatisfaction but also because of structural conditions that rendered the job unsustainable, both physically and emotionally.

Middle Management Staff: Fear and Risk Perception

Midlevel managers offered a distinct perspective, emphasizing both the perceived health risks of working during the pandemic and the mismatch between new hires’ expectations and the demanding realities of caregiving as key drivers of turnover. Trinity, a coordinator, explained:

It scared a lot of people. . . . I have young kids at home, so I was worried about bringing something back. Also, some new hires think caregiving is just playing games or doing makeup, but once they see the real work, such as bathing and dressing, they leave.

Trinity connects turnover to both emotional strain and mismatched expectations. Her concern about exposing her family reflects shared fears among staff during COVID-19. At the same time, her involvement in hiring gives her insight into how unrealistic assumptions about caregiving contribute to early exits, reflecting her unique point between staff and leadership.

Administrators: External Factors

Administrators, by contrast, framed turnover as driven by external cultural and policy factors. During the COVID-19 pandemic, the state of Oregon implemented expanded unemployment benefits through federally funded programs such as the CARES Act. These included Pandemic Unemployment Assistance, Pandemic Emergency Unemployment Compensation, and weekly Federal Pandemic Unemployment Compensation supplements (Oregon Employment Department n.d.). These policies were designed to support those who lost work due to the pandemic and were consistent with national trends. In fact, according to Parker and Clark (2021), only 3 percent of surveyed workers in Oregon reported not seeking employment because their unemployment benefits exceeded potential job earnings. However, based on the interviews with administrators at Harmony House, these benefits were sometimes perceived as disincentives to work, fueling frustration and debate about staffing shortages. The policy landscape thus served as a rhetorical resource that shaped how administrators made sense of turnover.

For example, Henry pointed to government unemployment benefits:

You have a government offering people so much money to stay home . . . that was kind of a tough situation.

Henry’s framing externalizes the cause of turnover, attributing it to public policy rather than organizational limitations. This view is echoed by Ralph, who blended political critique with cultural judgment:

The governor of Oregon . . . rewarded those who chose not to go to work . . . unlike other states that rewarded people who showed up.

This narrative reframes turnover as a moral failing of governance and of the younger workforce rather than a reflection of poor working conditions. Ralph’s invocation of generational work ethic signals a deeper ideological divide in which cultural stereotypes and political dissatisfaction converge to rationalize staffing issues.

Simon, another member of the leadership team, focused on accountability and hiring practices:

A lack of accountability is a major reason for high turnover. . . . The best thing I can do for a good employee is to get rid of the bad ones. But we can’t afford to do that.

Simon’s remarks reflect the constraints of managing under conditions of scarcity. His emphasis on “bad hires” and lenient policies reveals a perception that turnover stems from individual failings rather than systemic pressures, an outlook that risks alienating committed staff while failing to address deeper structural causes.

These divergent explanations illustrate a significant disconnect in how different roles within the organization perceived the root causes of turnover. They also demonstrate a fragmentation in understanding across organizational levels, which could hinder cohesive strategies to address turnover and improve staff retention. Frontline workers emphasized material and emotional exhaustion, mid-managers focused on perceived risks and mismatched expectations, and administrators invoked policy failures and cultural narratives. This disconnect reflects broader labor dynamics within long-term care: Those closest to the work experience its emotional and logistical burdens most acutely, and those in power often explain instability through externalized, individualizing frames. Failing to close these interpretive gaps may lead staff retention strategies to replicate the very dynamics that drive employees away.

Discussion and Conclusion

Building on scholarship on emotional labor (Hochschild 1983; Lopez 2006), care work (James 1992; Rodriquez 2014), and the theory of emotional stratification (Turner 2010), this article examined how employees positioned differently within the institutional structure navigated the dual pressure of emotional exhaustion and organizational instability due to high turnover during the COVID-19 pandemic. This study provides empirical insights into how high turnover rates impacted employees’ emotions in ALFs during the pandemic. Through 29 interviews, Harmony House employees from various positions within the facility shared how the heightened workload resulting from high turnover rates during the pandemic impacted their emotional responses and coping strategies. In addition, participants shared varying perspectives on the factors contributing to fast turnover, shaped by their positions within Harmony House. The findings confirm and extend previous research in several significant perspectives.

First, the divergent emotional experiences of Harmony House workers across different roles during the pandemic underscore how emotional dynamics are deeply influenced by role-specific factors. Consistent with prior literature (Cole et al. 2021; Smallwood et al. 2021; Smith et al. 2024), frontline workers, tasked with direct resident care, often bore the heaviest emotional weight of their close, empathetic bonds with residents while enduring physical and emotional exhaustion from increased workloads. Middle management staff, by contrast, navigated the challenging intermediary role of balancing frontline needs with organizational objectives. Their responsibilities often included being on call, which heightened their fear and stress during the pandemic. Administrators, in contrast, focused on high-level strategy and operational efficiency, with their emotional experiences shaped by the burden of ensuring the facility’s overall success and staff morale. Therefore, they were the only group among the three who actively engaged in emotional self-regulation while also highlighting the importance of fostering positive emotions across the team at Harmony House, particularly when responding to questions about burnout or emotional well-being. Although all groups share the goal of delivering high-quality care and demonstrate emotional attachment to residents, as defined by Lopez’s (2006) concept of organized emotional care, their differing priorities often lead to misaligned expectations and emotional tensions. These dynamics illustrate Turner’s (2010) theory of emotional stratification because the hierarchy of roles influences emotional experiences and expressions. For instance, frontline workers may feel undervalued when managerial or administrative decisions seem to prioritize the facility’s financial health while potentially risking the emotional well-being and satisfaction of employees. These findings advance existing work by showing that emotional burdens on ALF employees were further exacerbated by high turnover and were unevenly internalized and rationalized across occupational hierarchies. Unlike many studies that examine turnover from the standpoint of exit, this study draws attention to the emotional toll on those who remain, a perspective largely overlooked in long-term care scholarship.

Second, frontline workers, middle management staff, and administrators offered distinct explanations for the high turnover rates observed during the pandemic, reflecting the emotional and interpretive differences shaped by their occupational positions, which advances the existing literature by illustrating how perceptions of turnover are not only structurally situated but also symbolically and affectively experienced across occupational hierarchies. Frontline workers largely attributed high turnover to overwhelming workloads, burnout, and insufficient emotional and financial support. Many expressed frustrations over inadequate staffing, which forced them to take on additional responsibilities, exacerbating stress and emotional exhaustion. Middle management staff, in contrast, felt that the job’s intrinsic challenges and the fear of infection during the pandemic made staff retention more difficult. Administrators, however, emphasized external factors, such as government financial incentives, shifting work ethic among younger workers, and insufficient accountability among long-term care staff. From their perspective, high turnover was a consequence of external forces, which deflected structural responsibility (e.g., low pay, limited support). These differing explanations highlight the complex nature of workforce retention in long-term care settings. These misalignments highlight the urgent need for improved communication, mutual understanding, and empathy across all organizational levels to foster cohesion and enhance care quality. These findings advance the existing literature, which often adopts a top-down perspective, by highlighting the importance of a bottom-up view. Although the top-down perspective emphasizes how societal, professional, organizational, and cultural factors influence workers’ experiences, the bottom-up view showcases how individual roles shape perceptions of turnover’s causes. By integrating both perspectives, this study offers a more detailed understanding of how external pressures and internal dynamics intersect to shape emotional responses, introducing a complementary framework for future research.

In practice, recognizing these differing viewpoints is crucial for developing targeted interventions that address the specific concerns of each group. The study underlines the importance of tailored interventions that address the unique emotional needs of workers at different organizational levels. Consistent with previous studies on workers’ experiences of high turnover rates or burnout at work in long-term care facilities (Czuba, Kayes, and McPherson 2019; Kennedy and Mohr 2023; Yaraghi, Henfridsson, and Gopal 2022), the findings from this study suggest that in practice, organizations should adopt strategies that prioritize the emotional well-being of workers at all levels. Implementing communication methods such as town hall meetings or interdepartmental discussions can facilitate mutual understanding. These platforms allow staff to express concerns, share insights, and collaboratively identify solutions. Moreover, investing in initiatives such as employee recognition programs and flexible scheduling can mitigate burnout and reinforce a supportive workplace culture.

Third, the context of COVID-19 played a significant role in shaping emotional dynamics and turnover interpretations. For frontline workers, the pandemic intensified the emotional demands of caregiving while narrowing opportunities for emotional healing or support. For administrators, COVID-19 became a convenient but oversimplified explanation for structural shortcomings that preexisted before the public health crisis. Although the pandemic introduced real constraints, it also became a rhetorical resource, used selectively by those with institutional authority to account for rising instability. These contrasting attributions of the causes of high turnover, pandemic-related disruption cited by administrators versus low wages and perceived risk emphasized by frontline and middle management staff, are consistent with and help confirm core arguments of emotional labor theory. As Hochschild (1983) explains, different occupational roles come with distinct “feeling rules” that shape how workers are expected to manage and express emotions. In assisted living settings, administrators are often positioned to maintain composure and uphold institutional legitimacy, which may lead them to externalize structural problems and frame turnover as a temporary crisis driven by the pandemic. In contrast, frontline workers and midlevel managers, who are more emotionally and physically embedded in the daily realities of care work, experience greater emotional dissonance and moral distress when organizational demands conflict with their sense of duty and well-being. These workers are more likely to internalize systemic shortcomings, such as understaffing, safety concerns, and inadequate compensation, as persistent sources of strain. These differences show how institutional hierarchies are reproduced not just through formal authority but also through emotionally structured ways of seeing and interpreting workplace challenges.

Fourth, compounding this divergence in perspective is a generational narrative invoked by several administrators, who attributed high turnover to what they perceived as a lack of responsibility or commitment among younger employees. This framing reflects broader societal assumptions about young adults and risks individualizing what are fundamentally structural issues. Although such narratives may help maintain a sense of order or authority, they ultimately obscure the lived realities of staff navigating emotionally and physically demanding roles. In doing so, they may also hinder efforts to create more supportive and sustainable workplace environments. Frontline workers in ALFs are predominantly younger adults, with a significant portion employed in part-time roles. These employment patterns contribute to heightened job precarity, emotional exhaustion, and limited institutional support among younger staff. Despite these challenges, some administrators attribute high turnover rates to a perceived lack of work ethic among younger employees, framing the issue as a generational deficiency rather than acknowledging systemic factors such as low wages and inadequate support. This perspective not only overlooks the structural contributors to turnover but also risks alienating a vital segment of the workforce. Addressing these misconceptions and implementing supportive measures could enhance retention and improve the overall quality of care in assisted living settings. These findings call for future research to critically examine how age, employment status, and role expectations intersect to shape the experiences of frontline workers in assisted living settings. Moreover, research should investigate how generational stereotypes, such as assumptions about younger workers’ lack of commitment, circulate within organizational narratives and affect workplace culture, supervisory relationships, and policy decisions.

Although this study provides valuable insights, several limitations should be considered, as previously discussed in Yuan (2025). First, the research was conducted within a single ALF, which may limit the applicability of the findings to other long-term care settings. Second, the nursing home studied is well resourced and primarily serves affluent residents, which may shape employee experiences in ways that differ from those in underfunded or high-turnover environments. Additionally, the racial and ethnic composition of the resident population lacks diversity, potentially influencing the social and institutional dynamics captured in this study. As a result, the findings may not fully capture the experiences of staff in facilities that serve more diverse or socioeconomically disadvantaged populations. Although the qualitative approach allows for an in-depth exploration of participants’ experiences, the relatively small sample size restricts the generalizability of the results. Future research should examine multiple facilities with diverse organizational structures and workforce compositions to validate and expand on these findings. From a methodological standpoint, the reliance on in-depth interviews introduces the possibility of response biases, such as social desirability bias, where participants may present their experiences in a manner they perceive as favorable. To mitigate this, the study incorporated strategies such as open-ended questioning and establishing rapport to encourage candid responses, following Bergen and Labonté 2020. Furthermore, researcher reflexivity was maintained throughout the study to minimize interpretive bias, drawing on established qualitative methodologies (Pezalla, Pettigrew, and Miller-Day 2012; Watt 2007; Yoon and Uliassi 2022). Although a single researcher conducted the data analysis to ensure consistency, this approach may have limited the interpretive breadth of the findings. Future research could benefit from incorporating multiple coders or participant validation and follow-up focus groups to enhance analytical depth, credibility, and confirmability of the results. Lastly, the study focuses on the experiences of ALF staff and administrators, excluding perspectives from other stakeholders, such as residents and their families. Including these voices in future research could provide a more comprehensive understanding of the challenges and potential solutions posed by understaffing within long-term care settings given that residents and their families often experience the direct impact of understaffing, such as delayed care, unmet needs, or emotional distress.

Despite these limitations, this article has highlighted the voices of employees across diverse professional roles in the long-term care facilities and identified the divergent emotional impact of high turnover rates during the pandemic and the different explanations these employees offered to explain the reasons for the fast turnover in the industry, which demonstrated the inherent hierarchical nature of the distributions of emotions within an organization. The COVID-19 pandemic exposed the diverse emotional challenges faced by long-term care facility staff at all levels. The divergent perceptions of turnover reasons further reflect the complexity of addressing workforce stability during crises. Whereas administrators often externalized the issue by citing the pandemic or generational shortcomings, frontline and midlevel staff pointed to more immediate and enduring concerns, such as low pay, understaffing, and safety risks. These differences underscore how institutional hierarchies are reproduced not only through policy and power but also through emotionally structured interpretations of workplace challenges. By acknowledging these differences and commonalities, organizations can develop more effective strategies to support their teams, ensuring both individual well-being and operational sustainability in future emergencies. Future research that centers emotional labor across organizational levels, critically interrogates generational narratives, and includes member validation strategies can offer a more nuanced and equitable understanding of workforce instability in long-term care. Such efforts are vital for informing policies and interventions that genuinely reflect the experiences and needs of those most intimately involved in care work. Finally, further research across diverse settings is essential to deepen these insights and refine support systems for health care workers.

Supplemental Material

sj-docx-1-srd-10.1177_23780231251350173 – Supplemental material for Navigating High Staff Turnover: How Organizational Hierarchy Shaped Assisted Living Facility Employees’ Emotional Responses During the COVID-19 Pandemic

Supplemental material, sj-docx-1-srd-10.1177_23780231251350173 for Navigating High Staff Turnover: How Organizational Hierarchy Shaped Assisted Living Facility Employees’ Emotional Responses During the COVID-19 Pandemic by Yaqi Yuan in Socius