Rachel M. Werner, MD, PhD is the Executive Director of the Leonard Davis Institute of Health Economics, Professor of Medicine at Perelman School of Medicine, and Robert D. Eilers Professor of Health Care Management at the Wharton School at the University of Pennsylvania.

More than any other sector in health care, nursing homes have suffered during the pandemic. Nursing home residents and staff account for 34% of all COVID-19 deaths, though they make up less than 1% of the population. As a result of COVID-19-related concerns, the number of Americans living in nursing home has dropped by more than 10%. The result is an unprecedented financial crisis for the industry, with nursing homes closing their doors, some laying off their employees, and others being unable to safely staff their facilities.

Working conditions in nursing homes have also worsened during the pandemic—first there was too little equipment to adequately protect staff, then too few tests to routinely test staff, residents, and visitors. Staff have been overburdened, overworked, and burned out during the pandemic. Numerous reports of staffing shortages have emerged in the press, and nursing homes report severe staff shortages in data they submit to the federal government.

And so we were surprised to find, in a new study published in Health Affairs, that staffing levels in nursing homes did not decrease during the pandemic. Using auditable daily payroll-based staffing data from all U.S. nursing homes, we found that the total number of staff working in nursing homes fell, as did the number of nursing home residents. But when taken together—looking at the number of staff per nursing home resident—we found that staffing levels increased if anything, particularly in regions of the country hardest hit by COVID-19.

This is a counterintuitive result, and it flies in the face of conventional wisdom. Do we really believe that nursing home staffing is okay? No, we do not. To be clear—we believe that staffing levels did not decline during the pandemic. But we also believe that nursing home staff perceived a workforce shortage, which is perhaps more important. There are a number of reasons for this disconnect.

Norma B. Coe, PhD is Associate Professor of Medical Ethics and Health Policy at the Perelman School of Medicine and Co-Director of the Population Aging Research Center (PARC).

First, the workload of staff increased during the pandemic. Nursing homes banned visitors in an effort to protect the residents, but in doing so also banned the caregivers who provide daily help to feed, bath, and dress residents. Additionally, their work got harder. An hour of work before the pandemic did not go as far as an hour during the pandemic. Staff were required to regularly don and doff personal protective equipment, residents were spread out across more single-occupancy rooms, and, without the pre-pandemic routines and contact with family members, residents grew confused and agitated, requiring more care.

Second, stress at work increased. Staff have routinely reported shortages of PPE, fears of infection, and fears of spreading the infection to other residents or their own families. The perception of shortages may stem from the increased daily stresses that staff experienced. 

Third, stress outside of work also increased during the pandemic. The nursing home workforce is predominantly women, from low-income communities, often working multiple jobs. As the pandemic limited childcare and eldercare options, women had to fill in these roles at home, taking on double or triple caregiving duties, undoubtedly increasing stress and burnout at work.

Before the COVID-19 pandemic nursing home staff were overworked, underpaid, and undervalued. The pandemic has tightened the screws on this workforce. There are policies that could address this crisis in the short term— providing staff with universal access to testing, hazard pay, safe transportation, and expanded paid sick leave would be a good start. Over the longer term we must increase staffing levels in nursing homes, pay staff a living wage, and elevate the important role of nursing home staff in caring for older adults. Nursing homes are in crisis, one we cannot overcome without first addressing these longstanding and worsening staffing issues.

The article, Nursing Home Staffing Levels Did Not Change Significantly During COVID-19, was published in the May 2021 edition of Health Affairs. Authors are Rachel M. Werner and Norma B. Coe.