Study suggests staffing shortages during the COVID-19 pandemic placed strain on nursing homes

By Neha MathurAug 2 2023Reviewed by Sophia Coveney

In a recent study published in JAMA Network Open, researchers qualitatively examined staffing shortages in United States (US) nursing homes during the coronavirus disease 2019 (COVID-19) pandemic.

Background

Previous quantitative studies found mixed evidence of staffing shortfalls in US nursing homes during the early part of the COVID-19 pandemic. 

One study found that staffing levels did not decline during the initial pandemic phases. In contrast, another study by the Kaiser Family Foundation found that nursing home staffing shortages occurred alongside severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant surges, varying widely by state, and attained a whopping 34% in January 2022.

To steer through hard times when staffing was short, administrators increased staff workloads, decreased new recruitments, and offered wage raises to retain staff. Yet, even in 2022, only 2% of all US nursing homes worked fully staffed.

About the study

In the present study, researchers conducted four semistructured qualitative interviews virtually or by telephone at three-month intervals with participating nursing home administrators between July 14, 2020, and December 16, 2021, to enquire about the changes noted during the COVID-19 pandemic in nursing homes. They gave financial compensation to all nursing home administrators for participation.

They combined quantitative and qualitative methods for this convergent mixed-methods study to come up with three themes generated by qualitative analysis, which, in turn, helped the researchers develop four analytic measures for the statistical evaluation of facility-level data of each sample.

The team developed a refined interview guide for interview 1 covering open-ended questions about COVID-19 at nursing homes. For interviews 2 and 3, they modified it to include follow-up questions about the facility’s previous interview.

Before their third interview, all participants received a summary report of preliminary findings and emerging themes. So, they asked all participants to solicit feedback on the summary report during their third interview. The final interview had questions about administrator experiences over the 12-month interview period.

The team recorded interviews, professionally transcribed verbatim, and checked for accuracy. Next, they used grounded theory to develop an initial coding scheme adjusted iteratively to add and refine codes throughout data collection and analysis.

Two teams manually double-coded 102 interview transcripts. When all interview transcripts were coded, the team used the six steps outlined by Braun and Clarke to examine all codes related to a theme together.

For quantitative analyses, the team used the daily facility level Payroll-Based Journal (PBJ) data for January 2020-September 2022, which they used to generate four staffing measures to get a sneak peek into the sufficiency of staffing levels and quality of care given during the study duration.

They computed weekly means for all four analytic measures from 40 nursing homes and 15436 other nursing homes to evaluate temporal trends in the study sample relative to national trends for the same duration. 

A comparison of themes helped the researchers assess a connection between administrator experiences with nursing home staffing and facility-level data. Also, they explored whether their perspectives explained how they addressed staffing challenges.

Results

The study encompassed 156 interviews with 40 licensed nursing home administrators working in eight markets across the US. Some of them had over 30 years of experience. The researchers made three key observations about how US nursing homes dealt with the COVID-19 pandemic.

First, nursing home administrators used crisis management compensatory strategies to meet regulatory staffing minimums and maintain operations during the earlier part of the pandemic. They agreed that increasing resident-to-staff ratios, hiring agency staff, and decreasing resident census helped them care for residents despite staff shortages.

Second, these measures added extra financial costs for nursing homes already coping with rising operational costs amid the pandemic due to reduced resident admissions. Third, compensatory mechanisms adopted by administrators increased staff burnout. They had to manage higher caseloads, which might have resulted in poor resident outcomes.

Conclusions

Amid a public health crisis, US nursing homes strived hard to maintain minimally adequate staffing ratios and remain operational. The long-term consequences of these compensatory strategies remain incompletely understood but might affect the stability of an already strained workforce, thus, warrants more mixed-methods research.

Nonetheless, policymakers should review current regulations around staffing and work in US nursing homes to equip them for better crisis management in the future.