Experts on Camera

Dr. Jasmine Travers: Short-staffed nursing homes

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Eighty-four percent of nursing homes report moderate or high levels of staffing shortages, according to an industry survey from December.

On Wednesday, July 26, 2023, SciLine interviewed: Dr. Jasmine Travers, a gerontological nurse practitioner and an assistant professor of nursing at New York University Rory Meyers College of Nursing. She discussed topics including: how nursing home staffing affects quality of care and health outcomes for residents; her research showing that nursing homes in poorer neighborhoods are more under-staffed; how the COVID-19 pandemic has affected nursing home staffing; and what can be done to alleviate nursing home staffing challenges.

Declared interests:

Dr. Travers serves as an advisor to the AARP Public Policy Institute.

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JASMINE TRAVERS: My name is Jasmine Travers. I’m an assistant professor and a health services researcher at New York University in the Rory Meyers College of Nursing. And my research focuses on improving long term care delivery for older adults and improving workforce issues for those who work inside of nursing home settings.

Interview with SciLine

Who lives in nursing homes in the United States?


JASMINE TRAVERS: Just to step back, there are 15,000 nursing homes with approximately 1.2 million individuals living in nursing homes today. And that can range in age. So it’s not just older adults—although most commonly it’s those who are 65 years of age or older in the nursing home setting.

What services do nursing homes provide?


JASMINE TRAVERS: In nursing homes—different from assisted living settings—they provide around-the-clock care 24 hours, seven days per week. So that could be custodial care. So assistance with activities of daily living, such as eating, bathing, toileting, dressing—or they also provide skilled care services, such as rehabilitation care. You might have tracheostomy care, wound care, or IV therapy care.

What is the current state of nursing home staffing?


JASMINE TRAVERS: In 2001, CMS [Centers for Medicare & Medicaid Services] proposed some minimum staffing standards where—or minimum staffing recommendations of safe staffing, where they said that total nursing hours should be about 4.1 hour per resident per day. And that’s including the registered nurse, the licensed practical nurse, and the certified nursing assistants. And only 25% of those nursing homes—of nursing homes are found to be meeting those total nursing hours. And this was from a study that was recently conducted where that was found.

How has the COVID-19 pandemic affected nursing home occupancy and staffing?


JASMINE TRAVERS: Occupancy levels hovered about at 80% or more in the past 20 years. At the point of the pandemic, the lowest levels of occupancy went down to 67%. Right now, when the last numbers of occupancy were shown at the end of 2022, those levels have gone up to 72%, but still not up at 80%. So how we might view that when we see these changes in occupancy? When we have higher occupancy, we have higher residents that are taking up the beds within nursing home settings, which brings in higher revenue to the nursing homes. If there is lesser revenue coming into the nursing homes, then that’s a decrease in funds and financial support that the nursing home has to be able to run their day-to-day activities and to be able to staff the people who work in nursing homes. And you might say well, if occupancy is down, then, well that’s OK because then that would kind of even out when it comes to what we have to pay for the staffing that would care for those residents. But we have been severely understaffed in nursing homes prior to the pandemic. So it actually isn’t an apple-to-apple change, where we still see severe consequences when it comes to staffing. And if anything, during the pandemic the need for increased wages and bonuses and benefits has heightened because of the other competition that there is when it comes to other jobs and other settings. So nursing homes just have fewer resources to be able to pay for staff, which has been a significant issue within the nursing-home setting and continues to worsen.

How does nursing home staffing affect the quality of care and health outcomes for residents?


JASMINE TRAVERS: We have seen a number of studies that say that registered-nurse staffing—with staffing is low we see increased emergency hospitalization visits—hospital emergency department visits—and hospitalizations that could have been care that could have been provided in the nursing home setting. We see increased instances of pressure ulcers, lower instances of pain being addressed. For registered nurses, certified nursing assistants, when those staffing numbers are low, we also see increases in pressure ulcers, we see increases in deficiency citations and increases in urinary tract infections, for example, among residents. And then even when we think about our rehabilitative staff, like the physical therapists, we see increases in falls. And as we start to connect all of this together—and we’re like, oh, what does this really look like when it comes to staffing and being associated with poor outcomes when we have lower staffing? Just think about the nursing home setting. And when we have these numbers that we say: This is the number to provide safest amount of care—when we don’t have that number that means we might not have a sufficient number of nursing assistants, for example, to answer call bells. If we don’t have that number that we need to answer call bells and respond to residents needs, then that means residents are going to sit in their beds or sit, you know, needing help for longer periods of time. There are a number of residents who have voiced not having been able to see someone all day, who have voiced, have called someone for hours and no one has seen them, and they wanted things like to get out of bed to be toileted. So in those instances, if a person doesn’t have someone to get them out of bed, sometimes they might try to get up and out of bed themselves. And when they do that they could be at risk for falling. Or if they stay in bed and they’re soiled, they’re at increased risk for UTIs or increased risk for pressure ulcers. So these are the types of things that we see as a consequence of decreased staffing, which is an important issue that we really need to address.

How do socioeconomic factors affect the staffing available for a nursing home?


JASMINE TRAVERS: The socioeconomic level within a nursing home changes the desirability of a person to want to live in a setting and also to work in a setting—but also changes the aspects within that setting that makes it easier to get to a nursing home or not. So if there’s transportation within that setting, or if there’s lack of transportation in a more severely deprived setting, then a person most likely isn’t going to work in a nursing home in that setting or live in that setting. So if housing is poor, if education is poor it may not be a desirable place to actually work in. And then if a nursing home is located in these types of areas, we just might see fewer resources that are provided to those nursing homes to be able to create better working environments and provide better opportunities for better care for residents—which further just decreases someone’s desirability to want to work in those nursing homes versus another nursing home that has better resources, better support and is able to care for the workforce and the residents in enhanced ways.

What can be done to alleviate nursing home staffing challenges?


JASMINE TRAVERS: There are a number of things, and we can focus on two areas. There’s supporting staff that you already have and finding people in general. One of the biggest things when it comes to staffing challenges is the supply of people to actually fill those roles. So we need to increase the desirability to want to work in nursing homes and in areas that are socioeconomically deprived. Just recently, the Centers for Medicare and Medicaid Services—or the Department of Health and Human Services—released an announcement that they are going to allow for those who are in pediatric specialties to receive loan reimbursements and loan forgiveness for working in underserved areas. That’s what we need to also apply for those who are working in nursing homes and in nursing homes that are located in underserved areas, as well. So that’s something to attract the staff that would work in these settings. We need to improve wages and benefits for those who are working in the nursing home settings, especially as there’s a lot of disparity across settings and across other positions that people can work in and other places where people can work where they can get more pay. And without all of the disadvantages that—or the burden that sometimes can come with working understaffed and feeling unsupported. And just thinking about retention efforts: How do we keep the people who are already in our nursing homes? One of the biggest things when it comes to staffing is turnover that we’re not really paying a lot of attention in. We’re focused on meeting minimum staffing levels, but we’re not as focused as decreasing turnover. And turnover is associated with the work environment at these nursing homes. And we need to change the work environment so people will stay. When people stay longer, they know their residents more. That consistency translates to better quality of care for the nursing home residents.

How are reporters doing covering nursing homes?

[Posted July 26, 2023 | Download video]