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Staffing in Nursing Homes A Continuing Crisis in Care


Alicia has worked as a Certified Nurses Aide in a Bay Area nursing home for the past eight years. A single mother, with two children to support, she makes a little over $9 an hour working the morning shift five days a week. When she’s not forced to do a double shift because one of the other aides doesn’t show up, she can supplement her income cleaning houses. Caring for an average of 15 residents per shift (sometimes more depending on the staffing that day), her work is physically and emotionally draining, with little time for breaks or idle chatter with the residents. Although Alicia chose this area of work because she “liked working with the elderly” and wanted to become a nurse, given a choice, Alicia would find another job.

Alicia is not alone. With low pay for grueling physical labor, increased workloads due to staff shortages, poor training and supervision, few benefits and few incentives for advancement, it is little wonder that thousands of current and potential nursing assistants are looking elsewhere for work. These poor working conditions lower staff morale, lessen the ability to provide good care and result in one of the highest levels of injuries and stress related illnesses of any profession in the country, including back injuries, depression, heart disease and ulcers.

The human and economic impact on nursing home care cannot be overstated, as incidents of verbal and physical abuse of residents escalate, and resident neglect results in costly acute care admissions for infections, broken bones, dehydration, bedsores and pneumonia.

Staffing in California

Nursing Assistants (certified and uncertified) comprise 70% of the direct care hours in California nursing homes. Their wages comprise less than 50% of the total salaries for direct care. California requires 3.2 nursing hours per resident per day. While some facilities meet this requirement on paper, many do not meet this requirement in fact. A nursing assistant in California must complete 100 hours of on-the-job training and 60 hours of classroom training for certification. This training is often provided in the nursing home where they work. With no mandated staff-to-resident ratio and no uniform training, underpaid, untrained staff continues to be the biggest factor in poor care. Staff turnover rates in California exceed 80%.

AB 1075 (Shelley) was introduced last year as a partial solution to the understaffing problem. Adopting the “safe staffing standards” proposed by the National Citizens Coalition for Nursing Home Reform, AB 1075 would have phased in staff to patient “safe staffing” ratios by 2004.What started as an historic effort to implement safe staffing standards in all California nursing homes, however, ended in a vehicle for the nursing home industry’s long-sought reimbursement reform.

Despite a California Department of Health Services’ staffing study that found the majority of California nursing homes seriously understaffed, the final recommendation of the report was yet another study to determine if there was a link between increased staffing and quality.

Single Task Workers

Things aren’t much better at the federal level. In the summer of 2001, the federal Health and Human Services department issued a decision (bypassing public comment) that nursing homes can use untrained and unscreened workers to transport residents in vans or wheelchairs. HHS is also expected to release final regulations this fall to permit facilities to hire “feeding assistants to supplement the services of certified nurses aides.” HHS envisions feeding assistants as students, retired people and homemakers looking for a part-time job.

Using single task workers, who are paid less and trained less than certified nurses aides, is hardly the solution to the problem in our country’s nursing homes. What this will do is to allow nursing facilities to pay even lower wages, with no benefits, to another group of low-income people, with little or no training, to provide direct care to residents. It will clearly reduce the pressure on government and the industry to improve wages, benefits and working conditions, and inevitably result in yet another study.

What Can Be Done

The reasons for the staffing crisis in nursing homes are many: heavy workloads, low wages, high turnover, poor public perception of nursing home caregiving, lack of incentives for advancement and a state and national public policy that conveniently refuses to recognize the relationship between adequately trained and paid staff and quality of care.

Changes in public policy, professional practices and public education can address much of the problem.

Public Policy: In a system where the cost of care for nearly 80% of the residents is financed through public dollars, we can no longer pretend that the problem can be solved without increasing reimbursements. This reimbursement, however, needs to be based on accurate resident and staffing data and fiscal accountability. The acquisition excesses and Medicare fraud of the 90s should not be allowed to be repeated. Increased reimbursements should be directly tied to higher staffing and better wages.

Professional Standards: Uniform, standardized, professional training for nurses aides, before they begin providing hands-on care, should be implemented as a career program through the community college system. Until and unless we start promoting and funding certified nurses aides as a profession with incentives for advancement, rather than just a job that any 16 year old can do, facilities will not be able to recruit and retain qualified staff.

Public Perception: Nursing staff in nursing homes are too often perceived as the ugly stepsisters of the health care industry. Despite the fact that many are dedicated and committed to the delivery of care to our elderly and disabled, it is not until a consumer actually has a relative in a nursing home that he or she realizes the importance of qualified, caring nursing home staff.