Staffing nursing homes was hard before the pandemic. Now it's even tougher

Residents have fallen ill with the new coronavirus in both the Worcester, Massachusetts nursing homes where Kwaku Tsibo Bondah works.

Protective equipment is in short supply, he said, and many of his colleagues have tested positive or are calling in sick because they’re afraid to come to work. 

“It’s really challenging … everybody is in a state of anxiety,” said Bondah, a licensed practical nurse. “Because you are going into a room with someone who has COVID-19 there.” 

Many nursing homes and assisted living facilities were short-staffed before the coronavirus pandemic hit. Now it’s even harder to recruit and retain nurses needed to care for residents and stop the infection from spreading. 

When nurses and nurse aides are stretched thin, they end up cutting corners. They might fail to wash their hands often enough or try to lift a frail person by themselves—harming themselves or the people in their care, advocates and people who study the direct care workforce say. 

“We need to have enough staff to appropriately support the staff in there who are putting their lives on the line,” said Mairead Painter, Connecticut’s long-term care ombudsman. “When you’re working short, you make decisions you may not make on a good day.”

Governors and health agencies nationwide are developing “strike teams” of National Guard members and clinicians to help manage coronavirus outbreaks in long-term care facilities. But some state leaders also are trying to solve longer-term staffing problems. 

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Massachusetts and Colorado have launched websites to match job seekers with open long-term and residential care positions. Massachusetts is providing $1,000 bonuses for hires who stay on the job for a month, and Arkansas is boosting pay for nurses and other direct care workers from April 5 through the end of May. 

Illinois is among the states letting facilities hire nurses with an out-of-state or recently expired credential and temporarily hire unskilled workers to help feed and clothe residents—a role made possible for the time being by looser federal training and certification requirements for nurse aides.

To fix staffing problems over the long term, however, worker advocates say direct care workers need better pay. And that, industry groups and labor unions say, will require more state and federal dollars for long-term care.

“Post-pandemic, I think there needs to be a real conversation about valuing the roles of caregivers,” said Marlishia Aho, regional communications manager for 1199SEIU United Healthcare Workers East, a union that represents roughly 2,000 nursing home workers in Massachusetts, including Bondah. “And that requires wages that reflect the work that they are doing.”

Not Enough Nurses

Most U.S. nursing homes don’t have enough staff to provide the 4.1 hours of daily nursing care experts recommend, said Charlene Harrington, an emeritus professor of nursing and sociology at the University of California, San Francisco, who studies long-term care staffing.

“Seventy-five percent of all nursing homes did not meet the professional staffing standards that experts believed they should have before the virus hit,” Harrington said. “So that made them very vulnerable.” 

Care is mostly provided by nursing assistants, who have at least 75 hours of training and do everything from feeding residents and giving them medication to helping them move from a bed to a wheelchair. 

Instead of employing one nursing assistant for every seven residents—the minimum recommended by experts—some facilities employ one nursing assistant for every 10 or even 15 residents, Harrington said. 

There’s no standard federal ratio of staff to residents. A 1987 law requires nursing homes to have a registered nurse on duty eight hours a day, seven days a week; a licensed nurse on duty in the evenings and overnight; and staff “sufficient to meet nursing needs of its residents.” 

There’s no national data on nursing home staffing during the pandemic because the federal government has suspended staff reporting requirements to give businesses a break from paperwork. Before the pandemic, the average nursing home could provide 3.9 hours a day of nursing care per patient, according to the most recent federal data.

But workers, union leaders and industry groups say many workers are taking time off because they’ve contracted the virus, have caregiving responsibilities at home, or because they or a family member have a medical condition that makes them vulnerable to a deadly infection.

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“Many people are afraid to bring this home to their families,” said Aho of the SEIU. 

And jobs that already were empty are proving harder to fill as nursing homes and assisted living communities emerge as hotspots for coronavirus infections and deaths. 

A third of deaths from the virus in the United States have been residents and workers at long-term care facilities, according to The New York Times. In 13 states, including Massachusetts, it has been more than half.

Before the pandemic began, 1 in 7 direct care or nursing jobs at Massachusetts long-term care facilities were vacant, said Jennifer Chen, director of membership and engagement for the Massachusetts Senior Care Association, a trade association for long-term care facilities.

“We’ve seen this shortage of these nursing staff prior to COVID-19,” Chen said, “but the pandemic has really exacerbated the shortages.”

Despite the Massachusetts job website, the state hasn’t attracted enough applicants to meet demand, Chen said.

Some states also are allowing employers to hire temporary unskilled workers to support nurse aides.

Illinois regulators require “temporary nursing assistants” hired during the pandemic to complete 16 hours of instruction and training. Massachusetts workforce development officials are promoting “resident care assistant” jobs that don’t require any prior training or a high school diploma.

Using entry-level hires to perform simple tasks, such as holding up an iPad so isolated residents can video chat with loved ones, isn’t a bad idea, Harrington said. But it doesn’t fix the fundamental problem. 

“That would not, in any way, replace the needs for registered nurses or certified nursing assistants,” she said.

Not Enough Money

Worker advocates say long-term care nurses are underpaid. All types of nurses earn less in nursing homes than in hospitals, and low-paid nurse aides can struggle to afford rent and child care.

“We estimate that about 44% of direct care workers live in or near poverty,” said Robert Espinoza, vice president of policy at PHI, a New York City-based organization that works to improve direct care jobs. PHI’s estimate includes people who provide hands-on care in nursing homes, assisted living facilities, residential facilities for people with disabilities and clients’ own homes.

The average nurse aide earns about $13 an hour in a nursing home or assisted living center, according to the U.S. Bureau of Labor Statistics.

Many long-term care facilities have boosted hourly pay during the pandemic and at least one state, Arkansas, has won permission from federal regulators to offer bonuses: $250 a week for full-time direct care workers, and $500 a week for full-time workers who are caring for a patient who has tested positive for the coronavirus.

Industry groups acknowledge that pay is a problem but say employers’ hands are tied because their revenue depends on how much states pay them to care for people on Medicaid, the government health insurance program for low-income and disabled people.

In Massachusetts, 7 in 10 nursing home residents rely on Medicaid, Chen said, so state reimbursements dictate business revenue and therefore worker pay. “We can’t make these investments unless the state really makes these investments with us,” she said.

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State lawmakers, in turn, say plummeting tax collections will make it hard to increase Medicaid reimbursements anytime soon. Massachusetts’ fiscal 2021 revenue may be 15% lower than expected, according to the nonpartisan Massachusetts Taxpayers Foundation, a Boston-based research organization.

“Staffing and staff pay are at the very center of what we need to do,” said state Sen. Patricia Jehlen, a Democrat and Senate chair of the Joint Committee on Elder Affairs. She said she hopes lawmakers can improve Medicaid rates for long-term care facilities and better police how facilities spend the money.

But in the current budget environment, she said, “it’s going to be a very big challenge.”

Employers can improve direct care jobs without increasing hourly pay, said Katie Lynn-Vecqueray, director of employer membership at WorkLife Partnership, a Denver-based organization that helps employers retain employees.

Long-term care facilities can give care workers free meals, create support groups to help them manage stress or let them take mental health days, for instance. After low pay, Lynn-Vecqueray said, stress is a major reason why direct care workers quit.

Despite the pressure he and nurses like him are under now, Bondah said, he can’t think of any long-term care workers who have quit. He has been a nurse for 20 years, and he said he feels a duty to show people empathy and appreciation at the end of their lives.

“We need to give them good care,” he said of the residents he looks after. “We need to love them.”

Stateline is an initiative of The Pew Charitable Trusts.