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Chronic Understaffing in Nursing Homes and the Impacts on Healthcare

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Published December 15, 2022

Nursing homes have struggled to hire and keep staff for decades. Learn why the nursing home staffing shortage exists and what should be done about it.
Chronic Understaffing in Nursing Homes and the Impacts on Healthcare
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  • Understaffing in nursing homes has been a dangerous problem since the 1980s, and nursing homes have been aware of it.
  • The COVID-19 pandemic worsened the understaffing issues in nursing homes.
  • Nursing home administrators and staff can all be part of the solution.

Working in a nursing home became the most dangerous job in America when the COVID-19 pandemic started, according to U.S. News and World Report.

The COVID-19 pandemic heightened the nursing shortage happening across healthcare. However, the shortage of nurses in nursing homes has been chronic for decades. Staff-to-patient ratios were already at a dangerous level.

The pandemic came and worsened the causes of the shortage. Now, in the face of imperfect solutions, nursing homes struggle to hire and retain quality staff and keep their doors open.

COVID-19 Worsened the Nursing Shortage in Nursing Homes

Nursing homes already struggled to hire and keep staff before COVID-19. Poor pay, lack of respect, unsafe conditions, and unreasonable workloads worsened when the pandemic hit.

Despite certified nursing assistants (CNAs) making up the majority of the nursing home workforce and providing most of the direct nursing care for residents, CNAs are paid the least and are the most at risk for work-related injuries, according to the American Association of Retired Persons (AARP).

What's more, nursing home workers provided the same physically and emotionally demanding care, but in more hazardous conditions and with a smaller staff.

The COVID-19 pandemic added infection control issues to the staffing shortage. About 20% of nursing homes did not have enough personal protective equipment (PPE), according to Brian E. McGarry et al. in October 2020. Nursing home workers reused PPE or used inadequate quality PPE while providing care to patients with and without COVID-19.

The staff turnover rate before the pandemic was 94%, according to Health Affairs data from 2017 and 2018. During the pandemic, nursing home staff quit at higher rates than any other healthcare professional because they were unwilling or unable to work in unsafe conditions.

According to the American Health Care Association, as of June 2022, nursing homes still had dire understaffing levels on several fronts:

  • 87% of nursing homes experience moderate or high staffing shortages
  • 98% of nursing homes face issues hiring new staff
  • 73% of nursing homes may have to close due to staffing shortages
  • 60% of nursing homes are losing money
  • 53% of nursing homes cannot operate with their current costs and pace for more than a year

Nursing Homes Experience Low Staff-to-Patient Ratios for Decades

In 2001, Centers for Medicare and Medicaid Services published a study establishing the importance of minimum staff-to-patient ratios in nursing homes. The study suggests that nurses provide each nursing home resident with at least 4.1-4.85 hours of direct nursing care per day, depending on how long the resident stays in the nursing home.

These minimum hours should include a mix of care from registered nurses (RNs), licensed practical nurses (LPNs), and CNAs in varying amounts.

Because of poor funding, high staff turnover and burnout, and unsafe working conditions, many nursing homes do not meet these minimum standards. However, there are few consequences if nursing homes fall short of these safe-staffing standards. Nursing homes can remain open, and nursing home staff can keep their licenses.

Nursing homes and their staff will only face consequences if short staffing causes harmful outcomes for patients. Some of these harmful patient outcomes that can cause nursing staff to lose their licenses and become civilly and criminally liable include:

  • Deaths
  • Hospitalizations
  • Emergency room visits
  • Falls
  • Bedsores

To complicate things further, 30 states established their own mandatory minimum number of hours of direct nursing care per resident per day. All 30 states mandate fewer hours of direct nursing care than the national recommendation.

These state requirements are well below the individual healthcare needs of each resident. Nursing homes can also apply for waivers, provided by Congress, rather than meet the requirements in some cases.

The Role of Lawmakers in Nurse Staffing Ratios

Congress does not lay out specific rules for how much staff a nursing home needs to hire. Congress currently only requires long-term care facilities to provide:

  • Enough staff, including licensed nurses and CNAs, to meet the needs of all residents, according to their care plans
  • An RN, who serves as the director of nursing on a full-time basis
  • An RN, who serves as a full-time charge nurse
  • An RN for eight consecutive hours and seven days a week
  • CNAs, who show proficiency in skills they perform, get their license within four months of hire, and register with their state within four months of hire

Because Congress has not set mandatory minimum staffing requirements yet, states have taken it upon themselves to dictate staffing requirements. New York, Rhode Island, and Massachusetts increased their mandatory minimum staffing requirements. Other states such as Georgia, Oregon, and South Carolina temporarily or permanently decreased their requirements.

Mandatory staffing minimums may help staff-to-patient ratios, but currently, Congress has not set one. And states cannot agree on how many staff members should be required.

Nursing Homes Know the Risk of Low Nurse-to-Patient Ratios

Nursing homes have known about the dangers of short staffing since the 1980s. Yet, sometimes, they intentionally hire fewer people to cut labor costs.

According to Kaiser Health News, many nursing homes inaccurately represented how many people they had on the payroll and got away with it too. That is, until the Affordable Care Act in 2010 required nursing homes to turn in their daily payroll reports as a way to verify how many people were on staff.

About half of nursing homes failed to meet CMS recommendations for total staff 80% or more of the time between April 2017 and March 2018, according to Health Affairs data from July 2019.

Payroll data shows that all types of nursing homes did not meet CMS recommendations for the average hours spent with each resident. The average number of hours spent with each resident per day in for-profit nursing homes failed to meet even the lower requirements of the states, such as the 3.5 hours that California law requires.

LPNs do not face the challenges of poor pay, physically demanding work, and lack of advancement as much as RNs and CNAs do. In fact, nursing homes were mostly likely to staff the required number of LPNs.

Skilled nursing facilities pay LPNs the highest average annual salary, according to data from the U.S. Bureau of Labor Statistics (BLS), and they are not expected to do as much physical work as CNAs.

However, along with CNAs, nursing homes also offer poorer-than-average salaries for RNs, according to BLS data.

RNs may have more opportunities for advancement in other healthcare settings compared to CNAs. For CNAs, the physical demand of working in nursing homes is higher than if they choose to work in home health or assisted living.

Causes of the Staffing Shortage

  • Lack of respect for the work they do
  • Poor pay and benefits
  • Limited career advancement opportunities
  • Better-paying opportunities in other industries or healthcare settings
  • Unsafe working conditions and workloads

Effects of the Staffing Shortage

  • High turnover
  • High nurse burnout
  • Unsafe working conditions
  • Increased workload and overtime hours
  • Unsafe staff-to-patient ratios

What to Do About Low Staff-to-Patient Ratios?

Insufficient staff-to-patient ratios do not have an easy solution. Nursing homes get most of their funding from Medicare and Medicaid. CMS reimburses nursing homes with a bundled payment system, so nursing homes receive one lump sum per patient per day.

The nursing home decides, based on the patient's needs, the most important care for the patient. Many specialties fighting for a single pot of money means smaller salaries for staff and limited funds to hire new staff. Patients may not get care from all the specialties they need or for as long as they need.

Nursing homes solutions are incomplete and imperfect. Government officials from both political parties have tried to improve the quality and cost of nursing homes for decades with little success.

The most successful and workable solution will likely involve a mix of solutions from staff and nursing home leadership.

Congress could make a law that requires nursing homes to give each resident 4.1-4.85 hours of direct care per day. However, the law would be difficult to enforce.

The minimum staff requirements that some states passed may help patients, but a flat number of staff may not help patients who need more attention or direct care than average. Nursing homes can and have worked around minimum staffing rules by hiring temporary staff right before inspection.

Nursing homes try many different solutions to get more staff. However, they face issues because of the poor reimbursement rates and the lack of qualified or interested candidates.

To try to cope with the staff shortage, nursing homes may:

  • Ask staff to work mandatory or voluntary overtime
  • Rely on family members and unlicensed caregivers on weekends
  • Hire temporary agency staff
  • Limit new admissions
  • Promote staff
  • Increase wages and bonuses

High levels of turnover and burnout create an endless loop of staffing shortage in nursing homes. Nursing homes need good-quality CNAs, LPNs, and RNs to decrease the workload and make working conditions safer. Yet, good quality CNAs, LPNs, and RNs will find jobs elsewhere as long as nursing homes have such high workloads and unsafe conditions.

Nursing staff should help each other out when they can and make the most of the few resources they have. They should stick up for themselves, their coworkers, and their patients to minimize harm.

Sources

42 CFR § 483.35 -- nursing services. (n.d.). https://www.law.cornell.edu/cfr/text/42/483.35

Barr D. (2016). Introduction to U.S. health policy: The organization, financing, and delivery of health care in America. Print.

Esposito L. (2020). Expert: Nursing home workers have the most dangerous job in COVID-19.

https://health.usnews.com/hospital-heroes/articles/expert-nursing-home-workers-have-the-most-dangerous-job-in-covid-19

Feuerberg M. (2001). Appropriateness of minimum nurse staffing ratios in nursing homes. https://www.justice.gov/sites/default/files/elderjustice/legacy/2015/07/12/Appropriateness_of_Minimum_Nurse_Staffing_Ratios_in_Nursing_Homes.pdf

Gandhi A, et al. (2021). High nursing staff turnover in nursing homes offers important quality information. https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.00957

Geng F, et al. (2019). Daily nursing home staffing levels highly variable, often below CMS expectations. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.05322

Harrington C, et al. (2020). Appropriate nurse staffing levels for U.S. nursing homes.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328494/

McGarry BE, et al. (2020). Severe staffing and personal protective equipment shortages faced by nursing homes during the COVID-19 pandemic. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7598889/

Paulin E. Inside the 'staffing apocalypse' devastating U.S. nursing homes.

https://www.aarp.org/caregiving/health/info-2022/labor-shortage-nursing-homes.html

Pickering CEZ, et al. (2017). Recognizing and responding to the "toxic" work environment: Worker safety, patient safety, and abuse/neglect in nursing homes.

https://www.researchgate.net/publication/319110552_Recognizing_and_Responding_to_the_Toxic_Work_Environment_Worker_Safety_Patient_Safety_and_AbuseNeglect_in_Nursing_Homes

Rau J. (2018). 'Like a ghost town': Erratic nursing home staffing revealed through new records.

https://khn.org/news/like-a-ghost-town-erratic-nursing-home-staffing-revealed-through-new-records/

State of the nursing home industry: Survey of 759 nursing home providers show industry still facing major staffing and economic crisis. (2022). https://www.ahcancal.org/News-and-Communications/Fact-Sheets/Pages/default.aspx

Understaffing in nursing homes. (2022). https://www.nursinghomeabuse.org/nursing-home-neglect/understaffing/#:~:text=The%20most%20significant%20way%20to,at%20nursing%20homes%20are%20appropriate/

U.S. Bureau of Labor Statistics, Occupational Outlook Handbook. (2021). Licensed practical and licensed vocational nurses. https://www.bls.gov/oes/current/oes292061.htm

U.S. Bureau of Labor Statistics, Occupational Outlook Handbook. (2021). Registered nurses. https://www.bls.gov/oes/current/oes291141.htm

U.S. Bureau of Labor Statistics, Occupational Outlook Handbook. (2021). Certified nursing assistants. https://www.bls.gov/oes/current/oes311131.htm

What to do if a nursing home closes. (2020). https://www.nursinghomeabusecenter.com/blog/nursing-home-closure/

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