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Inside the 'Staffing Apocalypse' Devastating U.S. Nursing Homes

Workers have quit in droves, leaving residents without critical care

Sylvia Abbeyquaye
Sylvia Abbeyquaye quit her nursing home job after getting COVID-19 in 2020.
Olivia Falcigno

Sylvia Abbeyquaye, the director of nursing at a 120-bed nursing home in Brookline, Massachusetts, tested positive for COVID-19 just a few weeks into the pandemic. The virus severely inflamed her lungs, landing her in the hospital with bilateral pneumonia. “I didn’t think I was going to get through it,” she says.

Her workplace, meanwhile, kept calling. When was she coming back? It was April 2020, when the virus was spreading and more workers were out sick. More residents were dying. After six weeks off, Abbeyquaye, 48, returned to help combat the chaos. “But I never was the same again,” she says. “I was completely exhausted, burnt out and just down. ... I couldn’t take it.”

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She handed in her letter of resignation without another job lined up. “I just left,” says Abbeyquaye, who had worked in U.S. long-term care since emigrating from Ghana more than 20 years ago. “I didn’t know what the future was.”

The nation’s nursing home industry has shed roughly 235,000 jobs since March 2020, according to an analysis of U.S. Bureau of Labor Statistics data. That’s roughly 15 percent of the nursing home workforce, gone. The figure far outpaces the numbers lost in other health care sectors, which have also seen steep drops.

The Decline of Employees in U.S. Nursing Homes

Decline of Nursing Care Employees, in millions
AARP

And it’s not because demand for workers has decreased. Every month since summer 2020 — when the federal government began collecting COVID-19 data from nursing homes — has seen more than a fifth of nursing homes nationwide without enough workers, according to an analysis by AARP. Shortages have been at their worst this year, peaking between mid-December and mid-January, during the omicron surge, when 39 percent of nursing homes reported a lack of nurses and/or aides. In Alaska, Minnesota and Washington, over 70 percent of facilities reported staffing shortages.

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Workers say their exits are driven by dangerous working conditions, poor pay and benefits, limited opportunities for advancement, burnout and the respect deficit for their profession. Those issues were intensified by the pandemic, but they’re long-standing and deep-seated across the industry. “The foundations were so weak,” Abbeyquaye says. “COVID was just the last straw.”

Some workers have shifted to other health care roles in hospitals or private homes. Many have become travel nurses, who typically work temporary assignments in various short-staffed facilities for higher pay. Others have left for higher wages at places like Amazon and McDonald's. Some had to take on caregiving responsibilities at home or have opted for early retirement. Many immigrant workers have returned to their home countries. And many, like Abbeyquaye, just quit.

As staff flee, the health of nursing home residents has deteriorated, according to an analysis of federal data by the National Consumer Voice for Quality Long-Term Care. It found that in addition to the thousands of COVID-19 deaths among residents — now totaling some 170,000 — bedsores, weight loss, depression and the use of antipsychotic medication all rose during the pandemic.

The physical and mental health of workers is also deteriorating as they try to carry the excess load. A survey of nurses in hospitals, long-term care facilities and other health care settings by national staffing agency Incredible Health found that roughly a third of nurses said they very likely will quit by the end of this year, primarily because of stress and burnout.

The staffing crisis is forcing a growing number of nursing homes to halt admissions or close completely. A poll by LeadingAge, a national association representing nonprofit senior care providers, found that more than a third of its members are unable to admit new residents or serve new clients because of staffing challenges. And up to 40 percent of nursing home residents are living in facilities that are financially at risk of closure in 2022, according to Clifton Larson Allen, a wealth adviser for the long-term care industry.

The rapidly growing population of older adults, meanwhile, is expected to drive demand for nursing home care even higher in years ahead. The number of adults age 85 and older is projected to reach 19 million in 2060, up from 6.5 million in 2016.

“Many people would say that ‘crisis’ isn’t a strong enough word” to describe the shortages, said David Grabowski, a Harvard Medical School researcher who studies the economics of long-term care. “With the pandemic, we have a crisis on top of a crisis. ... Someone has called the current situation a staffing apocalypse.”

‘Living beyond paycheck to paycheck’

U.S. nursing homes were difficult places to work even before COVID-19. Staff turnover was already “astronomically high,” says Ashvin Gandhi, a health economist at UCLA and coauthor of a national study that found the median annual turnover rate for nearly all U.S. nursing homes in 2017 and 2018 was 94 percent. To maintain a staff of 100 employees over a year, a facility would have to hire 94 new workers annually.

That’s largely because certified nursing assistants (CNAs), who make up the largest group of nursing home employees, are among the lowest-paid workers in the health care industry, with a median annual income of roughly $30,000. Many are hired as independent contractors or part-time employees and don’t qualify for paid time off or health insurance. They often juggle multiple jobs to make ends meet; most who aren’t are providing unpaid care for family members, a recent study found. A disproportionate number are female, Black and immigrants.

CNAs provide around 90 percent of direct patient care in nursing homes: lifting, bathing, toileting, dressing and feeding. Before the pandemic, they were 3.5 times more likely to be injured on the job than the typical U.S. worker. Decades of chronic understaffing has meant unpredictable schedules, regular overtime and little support for training and professional development.

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Tamara Blue, 48, has worked two jobs at once — as a nursing home CNA and a home health aide in Detroit — for most of her 30-year career. In June, she gave up her home health work after her client died. Now she’s dedicating those hours to caring for her new grandchild, unpaid, but will likely have to pick up another home health job soon because “working one job is not enough for me.”

Tamara Blue and Debbie Dingell
Tamara Blue (right), a member of the SEIU Healthcare Michigan union, with U.S. Rep. Debbie Dingell (right) at a rally in July, 2021.
SEIU Healthcare Michigan

Working full-time hours on a part-time contract, she’s entitled to just 30 hours of vacation and sick leave each year. She gets dental and eye coverage from her employer but no other health insurance, and no retirement benefits or life insurance. She earns about $19 per hour, thanks to a recent Michigan law that temporarily increases pay for direct care staff by $2.35 per hour.

“We’re living beyond paycheck to paycheck,” Blue says. “You can’t afford to pay your whole rent; you can’t afford day care; putting gas in your car is a bonus. You work so hard, but you can’t put proper food on your table.” She adds, “We give our lives, we give our bodies, we give our hearts to these jobs, but when we get ready to retire, we have nothing to show for it.”

Blue works the overnight shift, with 16 residents to care for on a good night, up to 32 on a bad one. Both are above the state’s official standard of one direct care staff to 15 residents per night. “It takes a toll on the people who we care for,” she says. “CNAs are the first line of defense. We are the eyes and the ears for the doctors. ... When we are overwhelmed, a lot of things slip through the cracks.”

COVID’s toll

When COVID-19 hit, subpar working conditions got worse. Nursing home CNA became one of the deadliest jobs of 2020, as long-term care facilities accounted for more than a third of all U.S. COVID-19 deaths. More than a million nursing home workers have been infected with the virus, according to federal data, although that’s surely an undercount, given shortcomings in testing and reporting.

With droves of workers out sick and family caregivers barred from entering facilities amid 2020’s and 2021’s quarantines, overtime demands increased. And the work got harder, as more residents became severely ill and facilities faced evolving infection-control guidance and reporting requirements from health authorities. Government training waivers allowed facilities to quickly bring in more staff, but that intensified a lack of infection-control knowledge among workers.

Beyond the physical and mental toll, workers suffered emotional exhaustion. The mounting deaths were “a nightmare,” says Blue. “One day you’d lose another [resident], and the next day it’s the same routine, over and over again. You just had to take a deep breath, suck it all in and push forward. ... There was no time to grieve.”

As cases and deaths continue, that continues to be the case. “We’re still in a tornado of not really knowing what to expect,” Blue says, with nursing home cases rising once again. “I just push. We don’t take time to really think about what’s happened because I think if you really did, we’ll be like a whole lot of people and we’ll give up and walk away.”

Many nursing home workers felt forgotten as other health care workers were prioritized for personal protective equipment, tests and hazard or hero pay early in the crisis, adding to their anguish. And while other health care workers were lauded for heroic COVID-19 work, many nursing home workers were blamed for introducing the virus into facilities filled with vulnerable residents.

In northern Oklahoma, Lindsay Raupe, the director of social services at a faith-based continuing care center, grew anxious about going out into her community. She says she was once spit on while wearing her scrubs “because people were saying that it was us that was spreading” COVID-19. She also worried for her first-grade son, whom she sent to school in a mask to help protect her residents and who was bullied for it.

Raupe, 32, says her employer propped up its staff. “We’ve had amazing support,” she says, crediting the organization’s nonprofit status and modest size. “There’s not some corporate who doesn’t work day-to-day in my facility making decisions that affect my day-to-day. ... The people that are making the rules are the people that are the boots on the ground.”

Many workers haven’t been so lucky. Roughly 70 percent of U.S. nursing homes are for-profit, and more than half of those are operated by corporate chains. Private equity firms, whose business depends on short-term profits, own a growing share of facilities, currently around 11 percent. Studies show that for-profit facilities generally have significantly lower quality of care than nonprofit homes. For some, their “bottom line is how much money can we make, not what kind of care can we give to the residents,” says Patricia McGinnis, executive director of California Advocates for Nursing Home Reform.

Adelina Ramos
Adelina Ramos at her workplace in Rhode Island.
Courtesy of Adelina Ramos

Adelina Ramos, a CNA at a for-profit nursing home in Rhode Island, wonders why there’s no management working on weekends, “when we’re shortest,” she says. CNAs end up taking on management tasks, like dealing with last-minute worker scheduling changes and family complaints, scheduling visits and supervising wards, when “they should be giving patients the care they deserve.”

“These CEOs save money on short staffing,” says Ramos, 36. “They keep that money, and at the end of the year, they get big bonuses for themselves while we’re working short all the time.”

‘It’s like we’re throwing darts’

Some nursing homes have raised wages or offered sign-on or retention bonuses to stop the employee exodus. And some states have increased their minimum wage for nursing home workers. In fact, compared to other health care roles, nursing home jobs saw the largest wage increases in 2020 and 2021, according to a study in JAMA Health Forum. But employment levels in nursing homes continued to fall at a faster rate than in any other health care sector.

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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.”

Sylvia Abbeyquaye Stethoscope
Sylvia Abbeyquaye at Amory Park in Brookline, Massachusetts, on Tuesday, May 31, 2022.
Olivia Falcigno
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