Consensus Statement on the Staffing Crisis in Nursing Homes

The Nurse Staffing Crisis in Nursing Homes

Consensus Statement of the Campaign for Quality Care

This statement is endorsed by the following organizations (as of June 26, 2001):

Alliance for Retired Americans

Alzheimer’s Association

American Association of Homes and Services for the Aging

American Association of Nurse Assessment Coordinators

American College of Health Care Administrators

American Dietetic Association

American Federation of State, County and Municipal Employees

American Health Care Association

American Medical Directors Association

American Nurses Association

American Occupational Therapy Association

American Society of Consultant Pharmacists

Association of Jewish Aging Services

The Catholic Health Association of the United States

Center for Medicare Advocacy, Inc.

Dietary Managers Association

Food and Allied Service Trades, AFL/CIO

Institute for Palliative & Hospice Training, Inc.

John A. Hartford Institute for Geriatric Nursing

National Association for the Support of Long Term Care

National Association of Area Agencies on Aging

National Association of Directors of Nursing Administration in Long Term Care

National Association of State Long Term Care Ombudsman Programs

National Citizens’ Coalition for Nursing Home Reform

National Committee to Preserve Social Security and Medicare

National Senior Citizens Law Center

OWL

Paraprofessional Healthcare Institute

Service Employees International Union

United Food and Commercial Workers Union

United Jewish Communities

Nursing homes across the country continue to experience a staffing crisis that can jeopardize quality of care and life for residents.  This crisis includes insufficient numbers of staff, including certified nursing assistants (CNAs), licensed practical or vocational nurses (LPN/LVNs) and registered nurses (RNs).  The reasons for the staffing crisis are complex and multi-factorial.  Factors that contribute to the staffing crisis include issues related to:

Recruiting and Hiring of Qualified Job Applicants

Nursing homes have traditionally attracted staff who identify themselves as caregivers and as people who "want to help others.”  Unfortunately, factors such as workloads, wages and a public image of work in nursing facilities can make recruitment difficult.  This is exacerbated in times of high employment.

Retention

Retention of qualified nursing personnel is a particular and industry-wide problem.  Although turnover rates vary by region, various provider and other surveys indicate CNA turnover to be between 49 percent and 143 percent.  The most frequent reasons for leaving a job are unrealistic workload and low wages.  Lack of supervision because of shortages of licensed nurses also increases frustration and job dissatisfaction.  Many employees receive their CNA training to work in nursing facilities, and once certified, choose to work instead in acute care settings that can pay higher wages than nursing homes. These same surveys indicate the turnover rate for RNs ranges from 28 percent to 59 percent and for LPN/LVNs turnover ranges from 27 percent to 61 percent per year. The result can be a chronic lack of staff or dependence on agency personnel, an alternative that is costly in financial and human terms.

Payment Systems

Public payment systems finance the cost of care for nearly 80% of all nursing home residents through government payers, including Medicaid (67.6%) and Medicare (9%).  As both of these programs move from a cost-based to a prospective payment system, the policymakers’ intent is to control expenditures of public funds. Reimbursement levels through these programs, based on accurate resident and staffing data and fiscal accountability for use of reimbursement, must be adequate to employ and support enough staff and services to meet resident needs.  Care for frail elderly and seriously ill persons is labor intensive and costly.  Reimbursement levels are a significant determinant of providers’ ability to deliver optimal quality care.

Wages and Benefits

Inadequate pay for nursing staff in nursing homes contributes to the staffing crisis.  Due to differences in payment systems and other factors, RNs, LPNs and CNAs are usually paid appreciably less in nursing homes than they are in hospitals.  Many CNAs do not have retirement benefits and many who are offered health care benefits cannot afford to accept them because of the cost of deductibles, co-payments, and premiums.  Wages and benefits for all staff must be fair and competitive with those in hospital and other health care settings.

Education, Training and Supervision

Additional training would better prepare CNAs to care for the increasingly complex needs of residents living in nursing homes.  For the protection of residents, CNAs and LPNs legally must work under the supervision of RNs.  However, because more registered nurses are needed, many CNAs and LPNs do not benefit from sufficient hands-on advice and training.  RNs also need appropriate supervision and specialized training to address the unique needs of nursing home residents.   

Workload

In many nursing homes, CNAs, who provide most of the personal care, and licensed nurses, who also provide direct care, are assigned to more residents than they can properly care for.  In situations where unrealistic workloads exist, resident needs are often unmet, raising the risk of harmful and costly complications.  This frustrates those who feel responsible for the care of residents. The responsibilities of licensed staff have expanded as the percentage of residents with complex mental, physical, and psychosocial care needs has increased.  The workloads for licensed nurses have also grown due to an increase in mandatory record keeping and duplicative documentation that removes them from the frontlines.  Reasonable workloads are a necessary condition for quality care.

 Philosophy of the Organization/Staff Empowerment

While increasing numbers of homes are experimenting with and implementing new approaches that consider both staff needs and resident preferences/life-habits, work schedules and routines are often assigned without consultation or participation of staff or consideration of residents’ individualized needs.  Staff schedules that conflict with outside responsibilities can cause stress and job dissatisfaction.   Additionally, the structure of authority and responsibility in nursing homes tends to separate administrative nurses from staff nurses, and unit nurses from nursing assistants, and nursing assistants from residents.  This can affect a team approach to care planning and delivery.

 Workplace Safety

Adequate staffing is an essential component to workplace safety.  Insufficient numbers of staff or a shortage of appropriately trained staff can contribute to increased risk for staff injuries and  illness.  Too few staff leads to increased safety risks that can result in injuries to workers who then can suffer from the pain and long-lasting effects of back and other injuries.  Additionally, all staff are at risk of exposure to blood-borne pathogens and antibiotic resistant organisms.

 Opportunities For Advancement

While some nursing homes provide opportunities for CNAs to earn increased pay for increased responsibility, for many CNAs, the only options for advancement would require leaving nursing home work or obtaining the education to become a licensed or registered nurse. The latter is an option that many CNAs do not have the time, money or interest to pursue.  Incentives and recognition should be available for the many CNAs who choose to remain in their careers.  Historically, licensed nurses have had minimal education in gerontology or unit management – knowledge that is needed for promotion to higher-level positions such as Director of Nursing.  Opportunities for LPNs to pursue RN training and for RNs to pursue continuing education and advanced education degrees can also be prohibitive in time and cost.

 External Issues Such As Transportation and Child Care

CNAs, licensed nurses, and other personnel frequently face obstacles in affording the costs associated with employment.  For example, in many areas of the country the high cost and inaccessibility of public transportation make it difficult for nursing home staff to apply for, and remain, on the job.  Even for workers who have their own vehicles, parking fees, fuel, and maintenance expenses may be difficult to meet.

 Public Perception  

A negative public perception of nursing home care and caregiving has also been cited as a contributing factor to the staffing crisis.  There are many committed nursing home employees who deliver compassionate and competent care to residents.

 Conclusion