Because “it’s not just about the money,” says Abbeyquaye, “there’s anger. Workers don’t feel empowered, they feel belittled. … There’s an emotional piece that needs to be healed.”
Facilities are now offering a range of other benefits to retain workers, including subsidized housing and child care, flexible work schedules, paid leave, counseling and support groups, and free meal and grocery services. Some have created new roles, often called resident care coordinators, to perform nonclinical duties like making beds, delivering trays and answering phones, to ease the burden on CNAs and take advantage of hospitality and retail workers displaced by the pandemic.
“It’s like we’re throwing darts,” says Jacci Nickell, senior vice president of health care operations at Volunteers of America, a nonprofit operating more than 20 senior living communities throughout the U.S. “We’re like: ‘Hey, let’s see if this one sticks.’ ”
One new Volunteers of America strategy is allowing employees to travel between states to work across its short-staffed facilities at a higher hourly rate. Nickell hopes it reduces her organization’s reliance on external travel nurses, who can be very expensive and often don’t show up, she says.
Jennings, a smaller nonprofit long-term care provider in northeast Ohio, is installing ceiling lifts, which help residents in and out of their beds, to help prevent staff injuries. It’s also using new drug machines to dispense and package residents’ medication to free up workers’ time. And it introduced “stay interviews,” an alternative to exit interviews, to help retain employees. “We’re hoping that every little thing we’re doing somehow packaged together makes a big difference,” says Allison Salopeck, president and chief executive officer at Jennings.
Yet record-high staffing shortages persist. Volunteers of America lost more than 15 percent of its workforce during the pandemic, forcing it to suspend admissions. “We’re probably in the worst situation I’ve seen in 35 years,” Nickell says. Jennings is turning away patients referred by hospitals and hiring temporary workers for the first time in 20 years, with about 10 percent of staff now managed through temp agencies. “We just don’t get the number of applicants that we used to,” says Salopeck.
A national fix?
The crisis has captured the attention of President Joe Biden, who unveiled a slew of proposed nursing home reforms in February aimed at boosting the quality and oversight of the more than 15,000 facilities that participate in the Medicare and Medicaid programs. The plan includes reducing crowding in rooms, increasing health and safety inspections and fines, improving transparency of corporate ownership and more.
It also proposes a national minimum staffing requirement that could mandate certain amounts and types of care per resident. It’s well documented that high staffing levels translate into higher-quality care, but federal law only requires nursing homes to provide “sufficient” nursing staff to meet residents’ needs. Besides mandating that a registered nurse be on duty for eight hours a day, and that facilities have around-the-clock licensed nurse services, what counts as “sufficient” is subjective.
A 2001 report for the Centers for Medicare & Medicaid Services (CMS) found that at least 4.1 hours of direct-care nursing time per resident per day was required to prevent clinical decline in residents, but no such threshold is baked into federal law. Around 30 states have some kind of minimum staffing requirement, but most “fall far short” of the 4.1-hour threshold, according to a December report by the National Consumer Voice for Long-Term Quality Care.
The new federal rule for staffing minimums is not expected to be issued until next year, following a study to determine the level and type of staffing needed. In the meantime, some states are moving forward on their own. New York, Rhode Island, Massachusetts and others recently increased minimum staffing requirements for their nursing homes. Additional strategies include Iowa’s launch of an apprenticeship program enabling high school students to become CNAs before graduation and Illinois’ pledge of additional tuition reimbursement for students training in nursing home careers.
But other states have loosened standards. Georgia has permanently decreased its minimum staffing requirement, while Oregon and South Carolina have done so temporarily. Florida passed a law in April cutting the minimum hours of CNA care from 2.5 per resident per day to two. The law, which AARP strongly opposed, also broadened the types of care that can be counted toward the mandated minimum, further cutting the amount of nursing hours required.
The nursing home industry, meanwhile, is pushing back on a national staffing minimum, saying it’s unachievable with the worker supply shortage and unaffordable under current government funding.
“We would love to hire more nurses and nurse aides,” Mark Parkinson, president and CEO of the American Health Care Association, a national association of more than 14,000 for-profit and nonprofit long-term care providers, said in a statement. “However, we cannot meet additional staffing requirements when we can’t find people to fill the open positions, nor when we don’t have the resources to compete against other employers.”
Seen and heard for the first time
As many nursing home workers leave, hundreds of thousands of others are sticking with it. “I love my residents,” says Julie Martinez, a licensed practical nurse at a western New York nursing home. “Through the good and the bad.”
The national attention during the pandemic is making many nursing home workers feel seen and heard for the first time in their careers. “President Biden is giving us new hope,” says Blue, referring to his proposed reforms. “I keep working and I keep striving and I keep being positive because I am encouraged that if we hold on just a little longer, help will eventually come.”
And Abbeyquaye, who quit her job in 2020, has returned. For one day each week, she’s consulting at a small nursing home in Worcester, Massachusetts, helping it find and hire a director of nursing. Some days she finds herself on the floor instead, caring for residents due to staffing shortages. On the days she’s not there, she’s teaching nursing at Massachusetts College of Pharmacy and Health Sciences in Boston, helping shape the next generation of nursing home workers.
“When I grow old, I will go there,” she says of nursing homes. “Many of us will. So we can’t give up on it.”