Nursing Home Staffing Challenges Worse During COVID-19 Outbreaks

Nursing homes experienced significant staffing challenges during and after severe COVID-19 outbreaks due to temporary absences and permanent departures from workers, according to a study published in JAMA Health Forum.

The COVID-19 pandemic hit nursing homes particularly hard. As of May 2022, nearly 170,000 residents and more than 2,300 staff members have died. There were also more than one million confirmed COVID-19 cases among staff.

Like many other healthcare sectors, staffing shortages have plagued nursing homes since 2020.

Researchers used data from the CMS Payroll Based Journal and the National Healthcare Safety Network (NHSN) COVID-19 Nursing Home Data set to determine whether severe COVID-19 outbreaks were associated with declines in staffing.

They identified 39,390 COVID-19 outbreaks in nursing homes between June 14, 2020, and January 1, 2021. The mean number of resident and staff cases was 29.6, or 0.30 cases per bed.

The top decile was considered severe outbreaks, with an average of 135.1 cases and 1.5 cases per bed. The final study sample included 2,967 nursing homes with severe outbreaks.

Researchers found that nursing staff hours and resident census declined at the start of severe outbreaks and continued falling after the peak in average new cases.

For example, in week 4—when average new cases peaked—hours of nursing staff care were down 65 hours per week. By week 16, they were down 138 hours per week. After four weeks, resident censuses were down 4.9 residents and down 9.8 residents by week 16.

Since the decline in residents was steeper than the decline in staffing hours, nursing hours per resident increased during severe outbreaks, the study found.

During the first few weeks of an outbreak, average weekly nursing staff absences, departures, and new hires increased. In week 4, an additional 3.2 percent of the average staffing level was absent, 1.3 percent departed, and 1.5 percent were newly hired.

Absences remained high 16 weeks into an outbreak, but departures and new hires returned closer to baseline levels. However, departures outnumbered new hires between weeks 5 and 15, resulting in a net loss of staff members.

By week 16, the staff count was 5.1 percent below the mean due to the cumulative effect of additional departures relative to new hires.

Nursing homes frequently had staff work overtime and turned to contract staffing to address workforce shortages during an outbreak. Regular-time hours dropped within the first few weeks of an outbreak, but average overtime and contract hours increased during this time.

Regular-time hours declined by 5.5 percent of the mean in week 4, while overtime hours and contract hours added 1.3 percent and 1.4 percent of the mean to the staffing level. As a result, staffing hours were reduced by 2.6 percent in week 4.

However, the use of overtime and contract hours declined in the following weeks and regular-time hours continued to fall. By week 16, total staffing hours were 5.5 percent of the mean below pre-outbreak levels.

Certified nursing assistants (CNAs) saw the most significant decreases, with staff size down 4.7 percent of the mean staff count and 5.8 percent of mean hours. Registered nurse (RN) and licensed practical nurse (LPN) declines were significantly smaller because facilities had fewer CAN new hires compared with RN and LPN hires, the study noted.

Nursing home administrators were also more likely to report nursing staff shortages during outbreaks. The rate of administrators reporting staffing shortages was 10.1 percentage points higher during an outbreak's fourth week than in pre-outbreak weeks.

Additionally, nursing homes saw a rise in both COVID-19 and non-COVID-19-related deaths during outbreaks.

The study findings suggest that nursing homes should develop emergency staffing plans to ensure resident safety during future outbreaks. In addition, researchers recommended that policymakers could improve pay and benefits for nursing home staff and consider whether traditional staffing measures accurately capture the adequacy of staffing levels during a pandemic.