Nursing home administrators succeeded at meeting minimum staffing standards during the pandemic, but their crisis management practices came with financial and emotional costs, suggesting that policy makers need to rethink staffing regulations and increase sources of governmental funding for more persistent labor solutions.
These are the combined findings of two JAMA studies released on Tuesday.
The JAMA study recommending changes to staffing regulations used data from 156 interviews of administrators at 40 nursing homes across 8 health care markets that varied by region and nursing home use patterns.
Among the strategies used by administrators to comply with regulations and maintain good resident care, they cited increasing resident-to-staff ratios by hiring agency staff, and reducing resident census. However, even as these practices alleviated staffing issues during crisis mode, their overall impact was negative for resident care, revenue and worker wellbeing.
“Increased staff overtime pay, the high cost of agency staff, and the decreased revenue from new resident admissions has had major financial influences on nursing homes already coping with high operational costs due to the pandemic,” researchers noted.
Moreover, these practices – while useful at the time for skilled nursing facilities – tended to compromise resident care, especially as the trend of temporary staffing has continued past the pandemic.
“[The] stop-gap compensatory mechanisms administrators used to maintain operations have only exacerbated staff burnout,” the researchers said. “Policymakers should consider reviewing current nursing home regulations around staffing and work with nursing home administrators to create policies that more nimbly adjust to crisis management.”
The study noted that not only have staff had to manage higher caseloads, they have had the additional burden of supervising and training temporary agency staff unfamiliar with facility protocols. “This raises concerns for quality of care at nursing homes as staff burnout and high turnover have been reported to be associated with poor resident outcomes,” researchers noted.
The study suggests looking beyond simple staffing ratios since these don’t take into account complications stemming from hiring and training of agency staff.
“Staffing ratios alone are an incomplete picture of the staffing environment in nursing homes, particularly in the midst of a public health crisis …. The long-term consequences of these compensatory strategies will likely greatly affect the stability of an already strained workforce,” researchers concluded.
The administrator interviews were conducted between July 14, 2020, and December 16, 2021. Meanwhile, publicly available national Payroll Based Journal (PBJ) data were retrieved from January 1, 2020, to September 30, 2022. And, staffing and resident measures were derived from PBJ data and compared with national trends for 15,436 US nursing homes.
A call for ‘sufficient and sustainable’ funding
Another JAMA study related to staffing suggests that dedicated funding programs for staffing may be associated with increased nursing home staffing hours.
The federal government’s Paycheck Protection Program (PPP) was effective in supporting nursing homes by improving staffing levels at the height of the pandemic, the study found. Staffing hours changed among nursing homes that received forgivable loans through the PPP, which required recipients to appropriate 60% to 75% of the loan toward staffing.
In analyzing financial data from 6,008 U.S. nursing homes 12 weeks after they received a PPP loan, researchers said nursing homes that received such a loan saw a rise in certified nursing assistant (CNA) and licensed practical nurse (LPN) hours per week compared with nursing homes that did not receive a PPP loan. However, no link was found between PPP loan receipt and registered nurse (RN) staffing hours per week.
About 1,807, or 30%, of the nursing homes in the study received a PPP loan, the average loan amount being $664,349.
“Because the PPP loans are temporary, federal and state entities may need to institute sufficient and sustainable support to mitigate [nursing home] staffing shortages,” the study concluded.
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