Even After Infectious Outbreaks, Such as COVID-19, Nursing Home Staffing May Never be Fully Replaced

Decline is most notable among certified nursing assistants.

Infectious disease outbreak preparations in nursing homes should include emergency staffing plans, such as centralized "strike teams" that can be temporarily deployed to provide supplemental staffing, a recent study says.

The study, Staffing Patterns in US Nursing Homes During COVID-19 Outbreaks, noted that significant staffing declines during a severe COVID-19 outbreak continued even as much as 16 weeks after the outbreak's start. And even though facilities temporarily increased hiring, contract staff, and overtime to boost staffing, these measures did not fully replace lost staff—particularly certified nursing assistants (CNAs).

Karen Shen, PhD, co-author of the study of the John Hopkins University Bloomberg School of Public Health, said she and her team had heard about staffing challenges at nursing homes, but hadn't seen any measurable research on it. Other papers examining nursing home staffing, Shen said, were showing that there wasn’t a real issue.

Because of this, Shen and her team conducted their own study to examine the relationship between COVID-19 outbreaks and nursing home staffing patterns.

"We looked at about 3,000 facilities who had what we called severe outbreak in the second half of 2020," she said. "The average facility in that sample experienced an outbreak where they had 135 staff and resident cases—so big outbreaks—and we were curious what happened to staffing during those."

Using the facility’s daily staffing payroll data from June 2020 to January 2021, Shen and her team measured facility staffing, absences, departures, and the use of overtime and contract staff per week. They found that severe outbreaks were associated with a significant drop in staff due to elevated absences and departures.

For example, four weeks after an outbreak began, staffing hours were 2.6% below the mean of preoutbreak levels—even with "substantial" measures such as overtime and increased hiring being used to bolster facility staff. With those being temporary measures, staffing continued to decline—16 weeks after the beginning of an outbreak, staffing hours were 5.5% below the mean of preoutbreak levels.

"What we [found was] that when the outbreak is at its peak, it's about half and half, but because those people are coming back and people stop being absent, we find that a few months after the outbreak, there's still an effect where there’s a lot fewer staff at the nursing home than when the outbreak started," Shen explained. "But it’s almost entirely due to the increased turnover during the outbreak."

The decline was most notable among CNAs, according to the study's data, which could be due to the lower increase in new hires compared to licensed practical nurses (LPNs) or RNs. Shen said this decline wasn’t because CNAs were more likely to be absent or leave a facility—both scenarios occurred equally with CNAs, LPNs, and RNs. Rather, the facilities opted to hire more contractors or ask current staff to work overtime.

"I think it says something about the CNA pipeline, especially right now, being potentially the most constrained and probably because they’re just not offering good enough wages or benefits for someone to want to take that job right now," she said.

The results of the study suggest a need for policies that would ensure a facility's ability to maintain adequate staffing levels both during and after an infectious disease outbreak.

"We think it makes sense to send strike teams to nursing homes that might be experiencing large outbreaks and might be experiencing staffing shortages so we can make sure that patient care isn’t affected," Shen said.

"And I think in the long term, some of the things we talked about [were] just improving the pipeline of workers—in particular CNAs—into nursing homes by making those positions more attractive," she said. "One way that policymakers could do that is by potentially increasing Medicaid reimbursement rates to nursing homes."