Too Little, Too Late?

Jasmine L. Travers, Ph.D., MHS, RN, is an assistant professor at NYU Rory Meyers College of Nursing and affiliated faculty of the Hartford Institute for Geriatric Nursing. She is an expert in nursing home staffing. She wrote the below for U.S. News.

Airplanes don’t take off unless they have sufficient staff, but nursing homes do.

In the United States, 84% of nursing homes report severe staffing shortages impacting residents’ quality of care, according to the American Health Care Association. For instance, if residents don’t have help getting up each day, they become frail. If they don’t have help to eat, they experience malnutrition. And if they aren’t changed, they remain in soiled clothing and could develop pressure ulcers.

But there is more to life than meeting our most basic needs, explains Margarite Grootjes, a nursing home resident in southeast Ohio. “It’s the need for sufficient staffing to allow for time for conversations, organizing your space and human interactions,” she says.

Just like an airplane needs a crew, staffing in nursing homes has been recognized as the most important indicator of quality of care and quality of life in the nursing home setting – and, to Margarite’s point, one’s own dignity and humanity. It is no surprise that hundreds of thousands of lives were said to have been lost during the pandemic due to severe staffing shortages and the missed care resulting from them. What’s more, low-income individuals and people of color persistently bear the brunt of the consequences associated with poor staffing.

To keep nursing homes from operating at unsafe staffing levels, federal regulators recently proposed, among other changes, a required minimum nurse staffing level and a 24/7 registered nurse presence at facilities.

Over three-quarters of the 15,000 U.S. nursing homes now fail to meet the proposed hours. Before this proposal, nursing homes only required an RN to be on-site for eight hours per day.

A greater RN presence has been associated with fewer hospitalizations and emergency department visits because of nurses’ advanced training, plus their ability to perform comprehensive assessments, respond to resident needs on the spot and make life-changing decisions. For Margarite, this involves “things that can only be done by RNs,” like the administration of her steroid medication to treat a multiple sclerosis flare she experienced.

Another consequence of inadequate staffing is long waits. “When you put on your call light and there is only one [aide] on the floor, you can wait 20-25 minutes before you see someone,” says Margarite. “You can be putting the light on because you dropped a pen on the floor or because you are experiencing a heart attack. They all get the same wait time.”

If the proposed rules are implemented, nursing homes not meeting minimum staffing levels would be required to publicly report this information. These rules could improve the care for hundreds of thousands of the 1.2 million residents nationwide and make nursing homes more accountable.

At the same time, the proposed rules are lacking.

For one, they are actually lower than past recommendations by federal officials of 3.56 total RN and aide hours per resident per day. The new proposed rules also leave gaps big enough to drive through – notably, neglecting the role of licensed practical nurses (LPNs) who currently make up the second highest proportion of the direct care workforce and make it possible for the higher-trained RNs to do their job. LPNs perform basic resident care tasks such as administering medication and monitoring vital signs, and work under the supervision of the RN.

Most importantly, the changes won’t solve the biggest problem in nursing homes: the chronic shortage of nurses and aides. Because of staffing shortages, in the summer of 2021, only 1 in 4 nursing homes were confident they could survive a year. Since the pandemic’s onset, more than 500 nursing homes have closed.

Nursing homes say they are unable to find workers despite increased wages, flexible scheduling, bonuses and widespread marketing. Nurse staffing agencies, which have been accused of price gouging during the pandemic and inflating the wages of temporary workers, have also made it difficult for nursing homes to compete for staff.

Beyond pay, the nursing home environment can be underwhelming. Nurses and aides have long lamented the limited training, lack of autonomy, lack of respect and the limited career pathways available in long-term care facilities. Without a change to make these environments better places to work, the proposed regulations won’t stem the exodus of nurses and aides to better-paying and more supported jobs.

Next, granting waivers for nursing homes unable to meet staffing standards does not address the fundamental reasons the requirements are there in the first place: to prevent harm to residents.

And critically, minimum staffing requirements will not go into effect for three to five years, but the average nursing home stay is only three to five years. Residents like Margarite who don’t see themselves living for much longer describe the proposed standards as being “too little, too late.”

As a researcher studying the long-term care workforce, I urge federal officials to take several steps in the next iteration of these regulations. We need to increase the proposed minimum staffing levels and include LPNs. Nursing homes need to be provided with resources that enable them to be successful. Specifically, they need a comprehensive recruitment plan, funding, emergency staffing solutions and increased support for nursing homes unable to meet the requirements and for those serving predominantly low-income residents and people of color.

Federal officials can also help build the pipeline of workers by implementing policies that support immigrants entering the long-term care workforce, extending federal training funds to include aides and facilitating partnerships between nursing homes and academic centers. And finally, the minimum staffing levels should be implemented sooner with support and resources, as well as incentives for early implementers.

However, it’s not just federal officials who can help ensure adequate nursing home staffing. State officials have a hand in supporting their implementation through the allocation of state funds and development of policies.

New Jersey, for example, has implemented reform that included improvements to nursing home staffing levels and an increase in wages for their long-term care workers, funded by 60% of their $62.3 million in state funds. Illinois has allocated $350 million toward incentive payments for facilities that increase staffing levels.

Residents and families should also feel empowered to hold nursing homes accountable by escalating issues with their ombudsmen and participating in resident and family councils.

Next time you board a plane, take comfort in knowing there are regulations in place to ensure your safety. Our nursing home residents deserve the same protections and dignity — before it’s too late.