Staffing Shortages, Staffing Hours, and Resident Deaths in US Nursing Homes During the COVID-19 Pandemic

Addressing Staffing Shortages in Nursing Homes: Does Relaxing Training and Licensing Requirements Increase Nurse Aide Staffing?

OBJECTIVE

To evaluate whether COVID-19-related nurse aide training and licensing relaxation policies improved staffing shortages in nursing homes.

STUDY SETTING AND DESIGN

Staffing shortages have been a long-standing concern in nursing homes, and states are experimenting with different approaches to enhance nurse aide staffing. We use the latest quasi-experimental difference-in-differences methods to evaluate the effect of relaxing training and licensing requirements in 19 states (treatment group) relative to the 31 states that did not implement such policies (control group). We analyze the combined effect of relaxing both training and licensing requirements, as well as the impact of relaxing each policy separately.

DATA SOURCES AND ANALYTIC SAMPLE

We obtain quarterly data on nursing home characteristics, including adjusted nurse aide hours per resident day (HPRD) from 2019 to 2023 from Care Compare, a federal website with quality information on all Medicare/Medicaid-certified nursing homes. After excluding outliers of staffing data (nurse aide HPRD > 5.25, or nurse aide HPRD = 0), our final analytical sample had 278,170 observations.

PRINCIPAL FINDINGS

The average nurse aide HPRD is 2.30 in the treatment group and 2.26 in the control group. Using the difference-in-differences regression analyses, we find no significant effect of the relaxation of training and licensing requirements on nurse aide levels (average treatment effect: -0.0001; p = 0.99). Similarly, separate analyses of training and licensing relaxation policies suggest that neither policy significantly impacts nurse aide staffing. Results are consistent when we adjust for staffing requirements, wage increase policies, and nursing home characteristics.

CONCLUSIONS

Our findings suggest that the relaxation of training and licensing requirements may not lead to improved nurse aide staffing levels in nursing homes. Policymakers need to consider other strategies to address persistent staffing shortages in nursing homes.

Nutrition and Oral Health in Care Homes: A qualitative study of stakeholder perspectives

BACKGROUND

An increasing proportion of older adults currently live in care homes, where many need support with typical conditions of this age group. Oral health is often overlooked due to the historical rationale of edentulism. The current presence of natural teeth in a larger proportion of this population means that poor oral health negatively impacts their quality of life. This study explores how nutrition and dietary intake affect the oral health of older care home residents by gathering insights from stakeholders, aiming to inform strategies to improve oral health through collaborative interventions.

METHODS

Semi-structured interviews were conducted with care home residents and family members, staff, and healthcare professionals. Relevant stakeholders such as researchers and policy makers were also included. Reflective thematic analysis of verbatim-transcribed interview recordings led to overarching themes, which were agreed by a subset of participants.

RESULTS

Family members and dentists mostly described general oral health of care home residents as deteriorating. Nutrition provided in this setting was perceived as plentiful and energy-dense, but concerns with weight loss encourages the addition of dairy fat and sugar. Common practices in care homes that raised concerns regarding dental health were the use of oral supplements high in sugar, 'grazing' behaviour, the use of thickeners and visitors gifting with foods and drinks high in sugar.

CONCLUSIONS

Meeting energy, medical and cultural requirements while maintaining oral health in older residents of care homes is challenging. Future research should explore strategies co-developed with relevant stakeholders to mitigate nutritional risk factors for oral health.

CLINICAL SIGNIFICANCE

Members of the dental team must consider the views and roles of direct and indirect stakeholders when considering the interplay between nutrition and oral health in care homes.

Revisiting hospital patient safety culture in China: a nationwide network analysis

BACKGROUND

Patient safety culture (PSC) is crucial for reducing medical errors and improving patient outcomes globally. This study aims to identify key improvement targets in China's PSC to promote a safer healthcare environment.

METHODS

Data were extracted from two national PSC surveys conducted in 2016 and 2020 and were analyzed using the 12-dimensional Hospital Survey on Patient Safety Culture (HSOPSC) 1.0 questionnaire. Central targets were identified through strength, closeness, and betweenness centrality. Network stability was assessed using the case dropping bootstrap method.

RESULTS

A total of 24,529 responses were included, with an average positive response rate of 63.92%. Teamwork within units had the highest rate, and nonpunitive response to error the lowest. Feedback and communication about errors showed the greatest strength (1.302), closeness (0.008), and betweenness (22), occupying a core node position in both genders and correlating strongly with communication openness. After the COVID-19 pandemic, the core node position of management support for patient safety has become more prominent.

CONCLUSIONS

While teamwork is a notable strength, there is room to enhance the nonpunitive response to errors. Improving feedback and communication practices can further bolster openness and collaboration within teams, leading to an overall healthier work environment.

Lack of mpox transmission in a long-term care facility despite widespread exposure: Kentucky, 2023

A certified nursing assistant at a long-term care facility worked 3 shifts while infectious with monkeypox virus providing direct care to facility residents. Despite exposures and a delay of 16days from symptom onset to diagnosis and public health notification, there is no evidence of transmission. We describe details of this health care-associated exposure, public health response, situational risk factors for transmission, and discuss factors that might have contributed to the lack of transmission.

Variations in State Essential Caregiver Programs for Nursing Homes During the COVID-19 Pandemic

Background: During 2020-21, states established essential caregiver (EC) programs which allowed nursing home residents to receive in-person supports during the COVID-19 pandemic. This study presents comparative data on the designs of these programs. Methods: We conducted on-line searches for federal and states' nursing home visitation and reopening guidelines published in 2020-22. We also compared differences between states with and without an EC program in COVID-19 infection and death rates among nursing home residents or the general population, nursing home staff shortage rates, and rankings on restrictiveness of social distancing policies. Among states with an EC program, we summarized key program characteristics. Results: Twenty states established nursing home EC program from late 2020 to early 2021. Compared to states without an EC program, states with the program had slightly higher COVID-19 infection rate but slightly lower COVID-19 death rate, similar nurse staffing and nursing aids shortage rates in nursing homes, and somewhat lower rankings on the restrictiveness of social distancing measures. Compared to CMS guidelines that banned indoor visits to nursing homes under defined circumstances from March 2020 to November 2021, state EC programs were much less restrictive in specifying caregiver visits, for example, visits were allowed when county COVID-19 positivity rate>10% (18 programs), when the resident was not vaccinated (20 programs), or when the nursing home was in a COVID-19 outbreak (13 programs). However, state EC programs might still prohibit EC visits in certain situations, such as when the resident was in transmission-based precautions (13 programs), that is, when the resident had a confirmed COVID-19 infection, had COVID-19 symptoms although not yet confirmed, or was in observation for developing COVID-19 infection in the 14 days of nursing home (re)admission. Conclusion: States with and without a nursing home EC program did not differ appreciably in COVID-19 infection and death rates, or staffing shortage rates in nursing homes, although states with an EC program might have slightly less restrictive social distancing policies. State EC programs varied substantially in key designs. Comparative evaluations are needed to understand the effectiveness of these programs.

Symptom management for people with advanced dementia who are receiving end of life care

PURPOSE OF REVIEW

This review aims to synthesise contemporary research on symptom management for people with advanced dementia who are thought to be in the final year of life. It highlights the unique challenges faced by palliative care and dementia care specialists, offering insights into the clinical decision-making required to support those with advanced dementia in various care settings.

RECENT FINDINGS

Recent studies indicate that people with advanced dementia often experience significant unmet palliative care needs, particularly regarding symptom management. Pain, breathlessness, and psychological distress are frequently mismanaged, which contributes to suboptimal care. Moreover, the unpredictable trajectory of dementia complicates the identification of end-of-life needs, which can result in fragmented care. Caregivers, both professional and family, struggle with managing complex symptoms, while family caregivers in home settings face added burdens in providing care without sufficient support.

SUMMARY

Palliative care for people with advanced dementia is currently inadequate due to a lack of tailored interventions, poor symptom management, and disjointed care systems. Enhancing training for caregivers, fostering interdisciplinary collaboration, and focusing on integrated care approaches across home and institutional settings are crucial to improving quality of life and symptom control for people with advanced dementia.

Stress-related coping and its relationship to well-being in nursing assistants and personal care aides in nursing homes and assisted living

INTRODUCTION

Professional caregivers (nursing assistants and personal care aides) in nursing homes (NH) and assisted living (AL) provide the majority of long-term residential care for persons with Alzheimer's disease and related dementias. Their work is stressful, but until recently, no measures were available to assess stress in this workforce. Using the new Long-Term Care Cope (LTC COPE) scale, this study evaluates the relationship of coping with staff demographic characteristics and outcomes; the findings can be used to develop and evaluate interventions to improve staff well-being.

METHODS

We used a cross-sectional online questionnaire completed by professional caregivers working in a purposive selection of 10 NHs and three AL communities in California, New York, and North Carolina. The sample included 391 professional caregivers and had a representative distribution by age; it was 87% female; 42% non-Hispanic/Latinx (NHL) Black, 25% NHL White, 20% Hispanic/Latinx, and 7% NHL Asian. Worker job satisfaction, mental health, and health-related quality of life were examined in relation to caregiver demographics and the following approaches to coping as measured by the LTC COPE: avoidance, adaptive psychological strategies, active engagement, maladaptive psychological strategies, minimizing emotional impact, and substance use. Statistical comparisons used non-parametric Spearman correlation coefficients.

RESULTS

Little difference in coping strategies was noted by sex and education; older caregivers used adaptive psychological strategies more than younger caregivers; and traditionally minoritized adults (NHL Black, NHL Asian, and Hispanic/Latinx), compared to NHL White adults, more often used adaptive and less often used maladaptive psychological coping strategies. The use of maladaptive and avoidance strategies was strongly associated with depressive symptoms, anxiety, and burnout.

DISCUSSION

Professional caregivers report using a wide variety of coping strategies, with multiple strategies being the norm, and both adaptive/engaged and maladaptive/disengaged approaches are common. Certain coping approaches are strongly linked to depression, anxiety, and burnout; attention to training and support of adaptive and positive coping may augment other efforts to improve job satisfaction and performance. The LTC COPE scale has the potential to guide and evaluate practices to improve workers' well-being.

Highlights

Professional caregivers in nursing homes and assisted living generally use multiple strategies to cope with work-related stress.Certain coping approaches are strongly linked to depression, anxiety, and burnout.The Long-Term Care Cope scale has potential to guide and evaluate practices to improve worker well-being.