Nursing Home Staff Shortage During a Pandemic: Interview with a Professor
Some nursing homes [in Alabama] have had zero outbreaks and have sufficient levels of PPE. Other facilities have had significant numbers of residents and staff testing positive for coronavirus.
Dr. Rita A. Jablonski, Professor at the University of Alabama at Birmingham School of Nursing
In June, the families of millions of senior-aged citizens across the U.S. breathed a collective sigh of relief when state governments finally began to loosen restrictions on outside visitation of nursing homes and assisted living facilities. For countless families, seeing each other in person again was the moment they had been praying for after months of fear and ambiguity about when —or if—they’d ever get to see their loved ones again.
In March, it became clear that stopping the spread of COVID-19 was no longer a possibility and that adult care facilities and nursing homes were the biggest hot spots of the virus. The first infamous case in which two-thirds of one of Washington state nursing home’s residents and 47 of its workers fell ill, causing 35 deaths, was just the beginning.
Another 7,700 facilities across the U.S. would face their own outbreaks, culminating in more than 40,600 coronavirus-related resident deaths between March and June—about 40 percent of national death toll—because of the age group’s particular vulnerability to the respiratory virus.
Thousands of adult care and nursing homes and closed their doors to unnecessary visitors for an untold amount of time while they worked to implement safe practices from the Centers for Disease Control and Prevention (CDC)’s guidelines, such as screening body temperature of visitors upon entry, wearing facemasks, mandating frequent hand washing, and stocking up on personal protective equipment (PPE).
As the U.S. begins to move past the initial emergency stage of the pandemic, states are introducing phase two, and businesses, including adult care homes, are reopening their doors. Now, economic analysts are trying to predict the timeline regarding how fast the U.S. will be able to dig itself out of the current economic hole that it’s in.
By and large, they agree there is plenty of room for optimism about the future of employment opportunity in the U.S. and the health of the stock market. However, those that are retired or approaching retirement, don’t have as much time to endure a slow economic recovery.
Experts have been warning for years that we are unprepared for the mass retirement of Baby Boomers. Census Bureau data shows that within the next 10 years, there will be 72 million people in the U.S. aged 65 and older, which will encompass one-fifth of the U.S. population (a 10 percent increase of that age group).
The fact that 70 percent of the 65-plus population requires some form of long-term care means that there is the very real possibility that the need for these services will overwhelm the existing infrastructure of senior care facilities and the network of medical professionals that provide the care.
Now, with concerns about the effects of the pandemic added to the already unbalanced equation, we talked to a professor, researcher and nurse practitioner to understand how recent events might have aggravated the situation.
Meet the Expert: Dr. Rita Jablonski
Dr. Rita A. Jablonski is a tenured professor at one of the top nursing programs in the country, the University of Alabama at Birmingham School of Nursing, and a nurse practitioner in UAB’s Memory Disorders Clinic. She received her BSN from Holy Family College, her MSN from LaSalle University, her post-master’s NP certificate from the University of Pennsylvania, and a PhD from the University of Virginia.
Dr. Jablonski is particularly passionate about helping individuals with dementia who reside in nursing homes and aims to create a pipeline of future nurse researchers interested in dementia care and the needs of family caregivers.
How Extensive is the COVID-19 Epidemic Among Nursing Homes?
Since May, all nursing homes in the U.S. have been required to report COVID-19 data to the federal government. Alabama, where Dr. Jablonski lives, has seen its fair share of COVID-19 outbreaks in nursing homes. According to the Alabama Nursing Home Association, over half of the 231 nursing homes in Alabama have at least one case of COVID-19 as of mid-June. This ratio is typical of what is going on in elderly care facilities throughout the country.
“Some nursing homes [in Alabama] have had zero outbreaks and have sufficient levels of PPE. Other facilities have had significant numbers of residents and staff testing positive for coronavirus,” Dr. Jablonski said.
The particular vulnerability of elderly people to the coronavirus has raised concerns not only for the residents of nursing homes and assisted living facilities, but also for the workers that come into direct contact with patients such as certified nursing assistants (CNAs), licensed practical nurses (LPNs), and registered nurses (RNs).
The past few months have given nursing homes and assisted living facilities the chance to prepare and avoid outbreaks at their own facilities, but also put a spotlight on the importance of our nation’s care workers and the struggles and risks they are facing.
Navigating the Risks of Healthcare Professional Exposure
Dr. Jablonski entered nursing almost 40 years ago, when there wasn’t much information about HIV/AIDS, which caused a similar wave of panic and confusion about how to safely treat patients.
“We did not routinely use gloves, even when doing invasive activities like starting IVs. We never used goggles when suctioning,” Dr. Jablonski said. “Early in my career, I realized that doing my job increased my risk of getting sick, even dying.”
Since then, the nursing practice changed to prevent nurses from getting poked by needles or splashed with body fluids and contracting HIV. But even with safe practices, there is still the risk of catching diseases.
So far, the Guardian has tallied nearly 600 COVID-19 related deaths among frontline care workers in its project “Lost on the Frontline,” which is counting the deaths of doctors, nurses and paramedics, as well as crucial health care support staff such as hospital janitors, administrators and nursing home workers.
“Younger medical professionals may not have been confronted with this reality until now,” Dr. Jablonski said. “This realization could decrease the number of persons entering the profession.”
While it’s difficult to say how many people are being dissuaded from pursuing a career in care due to the fear caused by the pandemic, any kind of deterrence of potential entrants is the last thing that the industry needs.
Care jobs, such as personal care and home health aide positions, are projected to grow five times as fast as overall job growth in the U.S in coming years. But the number of people projected to enter the industry is not nearly enough to compensate for it. Experts say that in the U.S. alone, there will be a shortfall of 151,000 paid direct care workers by 2030.
“The COVID-19 pandemic is concerning, and we have to make changes in order to decrease our risk of contracting it and spreading it to others,” Dr. Jablonski said. “But the real crisis right now is the lack of care and resources for the 6 million people with a dementia diagnosis and their 15 million caregivers.”
A Day in the Life of a Nursing Home Care Worker
One Oregon woman named Kristina (who wished to keep her last name private to avoid negatively affecting her reputation in the industry) has about six years of experience in direct care in the adult care industry. She told us her perspective on the experience of care workers during the pandemic and at large.
Echoing Dr. Jablonski, Kristina said that for healthcare workers in her generation, the coronavirus is the first major public health scare in which they have been at the frontlines.
“At first, a wave hit and it was panic,” Kristina said. “Now, everything at work has changed. There have been walls put up, people are wearing face masks … but all the things that [the CDC] is telling us to do are kind of the things that should have been done to begin with.”
Kristina, who has worked as a CNA in both a skilled nursing facility and an assisted living facility, shared her thoughts on the high expectations of productivity, understaffing, and insufficient pay that lower-level adult care workers are subject to.
“It was such a shock, the amount of work a CNA is required to do, and the pay is absolutely terrible,” she said. “There were days when I was constantly giving myself pep talks, just trying to tell myself, ‘Today’s going to be a good day.’”
CNA duties include measuring vital signs, helping patients to use the bathroom and bathe, housekeeping, preparing their meals, and dressing bodies to go to the funeral home, depending on the kind of facility in which they work.
In Oregon, where Kristina works, the average pay of CNAs is only about $16 per hour. But that wage is above the shocking national average wage of CNAs of $12.67 per hour.
Across workspaces—from hospitals, to assisted living facilities, to nursing homes and even home care settings—direct healthcare workers of all levels face an intense workload, physical and emotional burnout, and risks to their own health to provide the fundamental service of care.
When Dr. Jablonski was a CNA at a nursing home in the early 1980s, she looked after eight patients on day shift and 10 patients on evening and night shifts. About half of them required total care and the other half needed some assistance, but could perform tasks like showering themselves. With that workload, she said she “worked very hard and sometimes struggled to meet everyone’s needs.”
Dr. Jablonski says that today, one RN may be responsible for supervising the care of up to 60 nursing home residents and CNAs may be responsible for more than 10 residents—and often all of them require total care. “These numbers make quality care impossible,” she said.
In a private Facebook group poll referenced in an article on Nurse.org, thousands of long-term care and skilled nursing facility staffers from six states divulged the care professional to patient ratios at their workplaces. In the most extreme cases, the nurse-to-patient ratio may be 50:1 and the CNA ratio 30:1.
Facilities often hire fewer nurses and CNAs per patient than hospitals based upon the justification that their residents are more medically stable than hospital patients. But this mentality leads to understaffing, which not only stretches workers thin, but compromises patient care and leads to increased rates of elder abuse and neglect.
One study reported that as many one in four residents of nursing homes experienced at least one instance of physical abuse, while in the facility and it is estimated that only one in 14 incidents of elder abuse are formally reported.
From that perspective, having better staff to patient ratios would not only alleviate the workload that intensifies care workers’ stress levels, but increase their supervision and accountability.
The Future of U.S. Nursing Homes
The pressure that the coronavirus has put on our healthcare system has reminded us of the immense value that care workers have in our society, and especially, the risks that they expose themselves to on a daily basis.
The heartening worldwide demonstrations of appreciation for healthcare workers in the form of nightly rounds of applause during the onset of the pandemic are evidence of that, but praise is not enough.
The age of the coronavirus will pass, but as the 72 million Baby Boomers enter old age, care workers need to receive fair compensation, or we will not be prepared to support the next generation of our elderly.
“You’re tired and cranky but there’s something about it. It sounds corny, but it’s the satisfaction,” Kristina said. “Being able to hold yourself together while a family is falling apart—it is so trying, your heart breaks every single time. But for the family to come back three months later and tell you, ‘My brother and sister have grown closer together thanks to you.’ That is what draws people back to CNA work. Those are the people that end up staying.”
As a society, we are currently relying on the benevolence of care workers like Kristina—who are drawn to care work as a vocation, not for appealing working conditions or decent pay—to step up to the plate.