Tara Cortes

Appropriate staffing for our nation’s nursing homes has been debated for decades.

In 2001, a Centers for Medicare & Medicaid Services study identified minimum staffing levels to prevent harm and jeopardy to long-stay residents should be 4.1 hours per resident day (HPRD). However, inadequate funding, the inability to recruit and retain appropriate staff and the perception of nursing homes as custodial care for older people hampered any move to create a policy to ensure this level of staffing. 

The pandemic and its catastrophic impact on older people in residential care has put a spotlight on nursing homes across the country and highlighted the historical neglect of long-term care in our hospital-centric healthcare system, where nursing homes have been marginalized and even siloed.

Over the past several months researchers, industry and community advocates, lobbyists and legislators have debated the causes of the catastrophic loss of residents in long-term care during the pandemic. As a result, states, including New York, that have not had minimum staffing regulations are passing bills to ensure certain staffing levels. There is also a bill under consideration in Congress to set a federal standard for a minimum staffing of 4.1 HPRD with at least .75 hours being provided by a registered nurse.

As evidence over the years has demonstrated, nursing care given by professional nurses and appropriately trained nursing assistants results in better person-centered care with better outcomes.  However, addressing staffing without addressing the antiquated payment model and the difficulty recruiting the workforce for long-term care is like fixing only one leg of a three-legged stool.

We cannot afford to marginalize long-term care any longer: It must be recognized as an integral part of the healthcare continuum. Although residential long-term care is historically thought of as being simply custodial, the care needed in these settings is actually some of the most complex care delivered across the healthcare continuum.  Most residents have multiple chronic diseases and very often have dementia as well.

With the increase in the number of people living to 85 and beyond, and the increase in complexity of those living in residential long-term care, the need for quality nursing homes — nursing homes that provide the right care at the right time by the right staff — is more acute than ever. 

Competing with other settings

Funding of long-term care is one of the primary factors that impacts recruitment of an adequate workforce. To recruit and retain staff you need to pay at least market rate. Historically, compensation and benefits in nursing homes have been inferior when compared to  hospitals. The median salary for RNs in long-term care is $29.29/hour with a high range of $36/hour, while nurses in hospitals have a median salary of $32.10 with a high range of $44/hour. Most hospitals offer tuition aid to nurses to complete their bachelor’s or master’s degree in nursing while few nursing homes provide that benefit.

Certified nursing assistants in nursing homes across the US have a median annual income of $28,500 with a median hourly income of $12.93, which is 13% below the national hourly wage.

These  direct care workers — often the eyes and ears of the residents — are vastly undervalued, and they are often forced to work one or two other jobs just to make a living wage. Unless competitive and livable wages are provided to the long-term care workforce, recruitment and retention will continue to be a challenge.  

Education and standards

Another factor in the inability to recruit a prepared workforce to long-term care is educational preparation. Nursing educational programs emphasize the acute care of hospitalized patients reflecting the hospital-centric, disease-focused paradigm of healthcare in this country.

Very often, the first clinical experience nursing students have is in a nursing home, presumably to learn how to give bed baths and take vital signs. Students are not prepared to interact with people with dementia at this point of their education, with the result that they are afraid, feel inadequate and never want to go into a nursing home again.

The minimal standard of 75 hours of education needed to become a CNA in long-term care was established in 1987 and has not changed although the complexity of the care needed by the residents over the past 34 years has changed dramatically. Unless we prepare the workforce to embrace the opportunity to provide person-centered care for a diverse population with complex care needs, recruitment and retention of staff will remain elusive.  

Setting standards for minimal staffing in nursing homes is one step forward to ensuring a quality standard of care for the vulnerable population in nursing homes. But to regulate staffing without a payment system that supports it at competitive market rates and educational preparation that addresses the important role of the nurse and of the direct caregiver in long-term care, sets up the industry for another catastrophic scenario.

It is time to recognize that nursing homes are an essential component of the healthcare system and the care they must provide has become much more complex over the last several decades. There needs to be a systematic strategy to support them with an appropriate financial model and a well-prepared workforce. 

Tara A. Cortes PhD, RN, FAAN, is the Executive Director of the Hartford Institute for Geriatric Nursing and a professor of geriatric nursing at NYU Rory Meyers College of Nursing.