COVID-19 AND NURSING HOME STAFFING 1

Effects of COVID-19 on Nursing Home Staffing

Sandra G. Fleet

School of Nursing, James Madison University

NSG 462 Issues in Contemporary Nursing Practice

Professor Bethany Andrews, MSN, RN

November 15, 2020

Abstract

The staff to resident ratio in our long-term care facilities has been inadequate for years. This

recent pandemic has shed some needed light on the already understaffed long-term care facilities.

I present several reasons how this virus made the situation that has existed for years even worse.

I have listed recommendations on how to improve such unacceptable staffing conditions in these

facilities that house our most vulnerable population. I hope by the end of this paper you too will

see the need for state and federal regulations on nursing home staffing shortages and the impact

it has on the residents and the staff.

Some may call them nursing homes while others may call them skilled nursing facilities,

long-term care facilities, convalescent homes, or even old people’s homes. Regardless of the

term used to describe these facilities, they all have one thing in common. These facilities are

designed to provide residential care to the elderly or disabled when they can no longer care for

themselves at home or do not have family members that can give them the care they need at

home. The staffing at long-term care facilities is said to be based on the number of residents and

the acuity of those residents. From what I have seen it is based solely on the number of

residents. In my opinion, staffing in long-term care facilities has been below average for years;

however, due to COVID-19 the problem is much worse now than ever before.

With an already less than adequate number of staff, the pandemic hit and hit hard. The last

place the virus needed to be was the breeding grounds of a nursing home. With so many

residents in close quarters, the virus would spread like wildfire and that is exactly what has

happened in many facilities across the country. One by one, residents and staff members began

showing signs and symptoms of the virus. Having this vulnerable population test positive for

this virus was bad enough but having inadequate staff to care for them during this time was

heart-wrenching.

As staff members began testing positive, sick leave increased leaving an even heavier

workload on those remaining. Many of the labor pool staff members were terrified of

contracting this virus and did not pick up the open shifts leaving the facilities that depended on

them without ample staff to care for residents. According to Szczerbińska (2020), employees did

not show up for work because of the fear for their health and the health of their loved ones. The

remaining staff were left to work long hours, feeling helpless and frustrated. They saw resident

after resident begin to decline from the virus, some resulting in death.
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Many facilities relied on employees to cover multiple units in their facility. With the virus

raging, some guidelines restricted employees from entering other units within a facility to stop

the spread. With employees out due to contracting the virus and others on quarantine for

exposure, the previous use of employees from other units were not able to be utilized.

Employees could only work on the unit in which they had been working, and in some cases, only

certain areas of that unit.

Many of the LTC staff had other part-time jobs elsewhere (at hospitals, outpatient clinics or

other nursing homes), which increased the risk of transmitting the infection between the facilities

(Szczerbińska, 2020). Many staff members were not allowed to work in other facilities

especially if there was a positive case in a facility in which they work. Multivariate regressions

comparing demographically and geographically similar nursing homes suggest that 49 percent of

COVID cases among nursing home residents are attributable to staff movement between

facilities (Chen, Chevalier, & Long, 2020). The staff that were working in multiple facilities

were considered to pose a higher risk and were encouraged to disclose to administrators if they

had exposures or contact with identified COVID-19 cases in other facilities (Eckardt et al.,

2020). To stop the spread of the virus, all employees are screened each time they enter the

facility. Employees are asked to leave and call employee health if they have any objective or

subjective signs or symptoms of the virus. When this happens, those employees are sent to be

tested and are unable to return to work until the results come back. The employees testing

positive are immediately put on quarantine and all other employees they have been in contact

with are called for questioning and sent for testing.

While these safety measures are necessary to stop the spread in these long-term care facilities,

management has not been proactive in preparing for how to deal with the staffing shortage.
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While already barely functioning with a high resident to staff ratio, solutions to cover shifts still

are not in place. Many have put the blame on COVID-19 for the staffing shortage, but the

problem existed long before the virus. Many may argue that this is an aberration in the context

of a pandemic but data over many decades tell us, this is not the case (Davidson & Szanton,

2020). When you are already working with minimum staff there is no room for a call-out or

absence. If staffing were adequate in long-term care facilities, one or two employees out for

isolation would not have impacted the entire facility the way it has during this pandemic.

Davidson & Szanton (2020) also tell us the COVID‐19 pandemic has taught us failing to address

staffing and care models in nursing homes and skilled nursing facilities is in fact a public health

issue. Suggestions and ideas are always thrown around, but a suggestion or idea is useless unless

it is tested, tried, and put into place.

My suggestion would be to pay employees of long-term care facilities what they are worth to

care and provide for the residents of these facilities. Registered nurses and certified nursing

assistance are not knocking down the doors of these facilities. There is no incentive to really do

the best you can do. Recent graduates apply for jobs at these facilities and are hired immediately

due to the shortage. It is not until they have worked a few months with a 1 to 20 nurse to

resident ratio do they realize the amount of work and dedication it really takes. This is when the

resignations start piling up and these employees leave knowing they can get employed at a

nearby hospital making more money with less hours and less frustration. Long-term care

facilities are no longer just taking care of the elderly. These facilities house very sick residents,

psych patients, in which many nurses are not trained in dealing with, and individuals that really

should be on a med-surg unit. If employees of these facilities were paid better and had more
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incentives to want to work at such a facility, there would be less turnover, and a great dedicated

team of employees could be established.

Will our society learn from this? Have we not learned from past mishaps? Some say we

should have learned from the devastating effect of Hurricane Katrina with the disproportionate

number of nursing home residents that lost their lives. Given the similar lack of preparation and

reserves in the nursing home sector in the course of many other natural disasters, the coronavirus

disease 2019 (COVID-19) pandemic poses urgent questions as to whether healthcare systems

and professionals have learned from these experiences (Fallon et al., 2020). Now is the time for

lawmakers to come together and take this issue seriously. Minimum staffing regulations need to

be put in place at state and federal levels to prevent this shortage from happening in the future.

The minimum staff to resident ratio needs to be realistic. Our most vulnerable population

deserves better care and without proper staffing and supervision this will not happen.

Nursing homes are required by federal law to meet the needs of their residents and to

maintain the highest practicable level of well-being and this requires adjusting staffing to meet

the acuity levels of residents (Harrington et al., 2020). As I mentioned before, acuity is not taken

into consideration at most long-term care facilities. This must change if we are going to provide

adequate care to these residents. It is a known fact that infection risks increase when there is a

shortage of staff. I would urge lawmakers to visit these facilities and take interest in seeing

really what is needed daily to run a more than average nursing facility. I think everyone would

agree that an average nursing facility is not good enough for the population of people that reside

in them. If we learn anything from this pandemic, I hope inadequate staffing is one of them.
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References

Chen, M. K., Chevalier, J. A., & Long, E. F. (2020, August 03). Nursing home staff networks

and COVID-19. National Bureau of Economic Research.

https://www.nber.org/papers/w27608

Davidson, P. M., & Szanton, S. L. (2020). Nursing homes and COVID‐19: We can and should

do better. Journal of Clinical Nursing, 29(15-16), 2758–2759.

https://doi.org/10.1111/jocn.15297

Eckardt, P., Guran, R., Hennemyre, J., Arikupurathu, R., Poveda, J., Miller, N., Frum, J. (2020).

Hospital affiliated long term care facility COVID-19 containment strategy by using

prevalence testing and infection control best practices. American Journal of Infection

Control. https://doi.org/10.1016/j.ajic.2020.06.215

Fallon, A., Dukelow, T., Kennelly, S. P., & O’Neill, D. (2020). COVID-19 in nursing homes.

QJM: An International Journal of Medicine, 113(6), 391–392.

https://doi.org/10.1093/qjmed/hcaa136

Harrington, C., Ross, L., Chapman, S., Halifax, E., Spurlock, B., & Bakerjian, D. (2020). Nurse

staffing and coronavirus infections in California nursing homes. Policy, Politics, &

Nursing Practice, 21(3), 174–186. https://doi.org/10.1177/1527154420938707

Szczerbińska, K. (2020). Could we have done better with COVID-19 in nursing homes?

European Geriatric Medicine, 11(4), 639–643. https://doi.org/10.1007/s41999-020-00362-