Staffing: What’s your plan for the next pandemic?

Nursing homes stand as pillars of care for vulnerable populations, providing round-the-clock support and medical attention to residents. However, behind the façade of compassionate care lie formidable staffing challenges that threaten the quality and continuity of services. Specifically, nursing homes report difficulties with high rates of turnover, finding and hiring new staff, and training. These issues become more apparent and problematic during the COVID-19 pandemic, leading to a high number of complications and mortalities with nursing home patients.  

In February 2024, the Office of Inspector General published its third report on Lessons Learned During the Pandemic.  This article will review the OIG findings with respect to staffing issues and use of staff agencies during pandemic.

The report highlights some of the staffing challenges that nursing homes experienced during the pandemic, as follows:

• Many staff retired or left the workforce during the COVID-19 pandemic. The fear of contracting COVID-19 drove many staff out of the workforce in early 2020 and 2021.  The non-retiring migrating staff took jobs at other health care providers where they were paid higher wages and better benefits, had a better work-life balance or had more prestigious titles;
• Nursing homes struggled to find and retain staff for lower-wage positions such as certified nurse aides (CNAs), dietary services staff, and housekeeping staff. Nursing homes observed that individuals could find work in the fast-food industry, at big-box stores, or with delivery services for more money and less physical and emotional demand; 
• Burnout was another big issue among nursing home employees. Administrators noted that the staff feels overworked and underappreciated. 
• Nursing homes had also stressed that the hiring process was difficult, as candidates frequently drop out of the hiring process. For example, candidates did not come to interviews, failed to attend orientation after being hired, or did not show up for their first day of work.  

The pandemic only exacerbated an already existing problem.  There are many other important factors that contributed and continues to contribute to staff problems at nursing homes:

1. Recruitment Roadblocks: Despite the growing demand for skilled nursing professionals, nursing homes encounter roadblocks in recruiting qualified staff. Factors such as a nationwide shortage of nurses, competition from other healthcare sectors, and geographic disparities exacerbate recruitment woes. Moreover, stringent licensing requirements and educational prerequisites further narrow the pool of eligible candidates, leaving nursing homes scrambling to fill vacant positions.
2. Staffing Disparities: Nursing homes grapple with disparities in staffing levels, particularly in rural and underserved areas. Limited access to healthcare professionals exacerbates the staffing crisis, leaving residents in these regions vulnerable to gaps in care. Furthermore, disparities in nurse-to-patient ratios jeopardize patient safety and quality of care, as overburdened staff struggle to meet the diverse needs of residents. Addressing staffing disparities requires targeted interventions, including incentives for healthcare professionals to practice in underserved areas and innovative staffing models to optimize resource allocation.
3. Workforce Diversity Dilemmas: Nursing homes face challenges in promoting workforce diversity and cultural competency among staff members. The lack of diversity in the healthcare workforce undermines the ability of nursing homes to effectively meet the needs of an increasingly multicultural resident population. Cultural and linguistic barriers hinder communication and rapport between staff and residents, impeding the delivery of person-centered care. Nursing homes must prioritize initiatives to foster diversity and inclusion, including targeted recruitment efforts, cultural competency training, and creating a supportive work environment that celebrates diversity.
4. Regulatory Rigamarole:  Nursing homes grapple with regulatory complexities that dictate staffing requirements and standards of care. Compliance with federal and state regulations adds an additional layer of complexity to staffing management, requiring meticulous documentation and adherence to stringent guidelines. Staffing shortages and turnover can exacerbate regulatory compliance challenges, placing nursing homes at risk of sanctions, fines, and litigation. To navigate the regulatory rigamarole, nursing homes must invest in staff training, implement robust quality assurance measures, and maintain open lines of communication with regulatory authorities.

During the pandemic, staffing challenges forced nursing homes to rely on staffing agencies to fill gaps, which, according to the OIG study, had significant drawbacks, including high costs, unreliability, and unfamiliarity with systems and residents.

Nursing homes characterized staffing agency rates as exorbitant, especially during the most difficult period of the pandemic.  In some instances, some agency costs increased by 40 percent.  These high agency rates put many nursing facilities out of business.

Staffing agencies also paid higher wages than nursing homes, which created additional migration of staff from the nursing homes to staff agencies. The pay discrepancies further affected the morales, as agency staff would boast about their high pay and upset permanent staff who felt agency staff did not work as hard.

In addition to high costs, staffing agency staff were also unreliable and they had little resource when they arrived late or missed work. Nursing homes could not complain for the most part, out of fear of losing their contracts with the staffing agency.

Those staffing agency workers who did show up to work were less familiar with the facility, electronic medical records/narcotics systems and residents, leading to lower quality of care and regulatory issues.

The OIG report focuses on the interaction between nursing homes and staffing agencies during the pandemic period. However, under better circumstances, there are some benefits to hiring staffing agencies, including:

1. Flexibility: Staffing agencies provide nursing facilities with flexibility in staffing levels. They can quickly adjust the number of nurses based on patient needs, without the long-term commitment associated with hiring permanent employees.
2. Rapid Response: In cases of sudden staff shortages due to illness, vacations, or unexpected increases in patient load, staffing agencies can provide immediate replacements, ensuring continuity of care.
3. Specialized Recruitment: Staffing agencies often specialize in healthcare and have access to a pool of qualified nursing professionals. This saves nursing facilities time and resources in recruiting, as agencies handle the screening, credentialing, and hiring processes.
4. Cost-Efficiency: While the hourly rates for agency nurses may be higher than those for permanent staff, nursing facilities can save on expenses associated with hiring, training, benefits, and payroll taxes for full-time employees. This can be particularly beneficial for short-term staffing needs.
5. Reduced Administrative Burden: Staffing agencies handle administrative tasks such as payroll, scheduling, and compliance with labor regulations, relieving nursing facility staff of these responsibilities.

Finally, the OIG report highlights how nursing homes managed the staffing challenges during the pandemic by changing the work environment and using incentives, with mixed success.

A number of strategies were implemented to manage the dire staffing issues:

• Some nursing homes fostered an “all-hands-on-deck” approach that tasked non-clinical staff to distribute meals and helped with testing and vaccination reports to authorities. Administrators and directors covered whatever needed, such as coving floor shifts, in addition to their regular responsibilities.  However, this “all-hands-on-deck” approach causes higher turnover and burnout of the staff.
• Other nursing homes leveraged workplace culture to maintain morale and improve retention. They offered perks, such as free meals and massages, for example. The organizations kept open lines of communication with the staff and helped the staff with their daily challenges, such as automobile troubles. Some nursing homes offered bonuses and other incentives for staff who took additional shifts or had perfect attendance.
• Nursing homes also tried to lessen workload by keeping a lower census so they can provide better care and ensure adequate staffing. Others tried inventive methods to maintain the quality of care, such as creating an individualized, one-page care guide for each resident to allow unfamiliar staff faster understanding of the patient’s needs.
• To ensure they could attract the staff they needed, some nursing homes paid additional bonuses for new hires, for referring new employees and for staying through the trial period.  Others offered incentives such as higher wages, and enhanced benefits, such as 401(k) plans and tuition reimbursement programs.
• Two nursing homes created their own internal “staffing agency” to fulfill staffing needs. One noted that workers could make an additional $10 to $20 per hour in this program, but without benefits. The other noted the internal staffing agency allowed the nursing home to retain staff and manage performance more directly.
• Nevertheless, according to the OIG report, the success of these strategies was inconsistent across the nursing homes. Further, not all nursing homes could afford these strategies. 

In light of these findings, OIG has made a few general recommendations to strengthen the nursing home workforce:

• CMS has announced that it will partner with HRSA to lead nursing home workforce development by investing more than $75 million in financial incentives, such as scholarships and tuition reimbursements.
• OIG has further recommended that CMS should explore which additional tools it can bring to help alleviate nursing home staffing challenges. CMS could explore innovative strategies to develop workforce enforcement programs through the Center for Medicare and Medicaid Innovation (CMMI).  

As nursing homes confront the multifaceted challenges of staffing, resilience and innovation emerge as guiding beacons in navigating the turbulent waters of workforce management. By addressing recruitment barriers, enhancing retention strategies, promoting workforce diversity, and ensuring regulatory compliance, nursing homes can fortify their staffing infrastructure and uphold their commitment to delivering compassionate and high-quality care to residents. However, the burden of fixing this problem should not fall on the shoulders of the nursing homes, only.  The regulators must help by increasing pay and incentives to keep working at nursing homes an attractive alternative in the healthcare industry.

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