Friday Feature: Nursing and LTC

Each Friday (hopefully so), I will take a specific topic that has been in the news or been directly posed to me by a colleague or a reader and do a bit of a deep dive feature. This week it’s the future of nursing or more directly, nurses in senior housing and long-term care.

As I’ve discussed in other posts and in presentations I have done, the U.S. post the pandemic has a major nurse shortage – RNs and LPNs. The shortage is most noticeable at the bedside, hospitals and SNFs standing out. This is not to say that home health and hospice are immune from short numbers, but the most acute demand/supply contrast is found in inpatient settings. This shortage creates care problems and access problems. The typical admission/discharge cycles among providers are constantly interrupted such that patients are often stuck in one element or another of a care queue simply because not enough staff are available to provide care. I’ve seen all too many times over the past two years, SNFs not accept discharges, even of their own transfers, simply because staffing is inadequate in number to provide the care required.

To anyone watching prior to the pandemic, the shortage problem has been building. The pandemic exacerbated what was already a modest imbalance (more demand than supply). For various reasons from safety to mandates to burnout, COVID pushed retirement numbers for nurses and/or, created a disengagement from inpatient settings to other settings where nurses could work in a more even-keel environment, less taxing. Clinic settings, schools, software companies, lab companies, insurance companies, etc., all consume nurses, especially RNs. While the wage trade-off may be a few bucks or so per hour, the stability and scale of Monday-Friday, days only even some with full remote work, pulled nurses away from hospitals and SNFs.

The demographics in terms of age illustrate nursing to be an older profession. In other words, the nurses working are more seasoned in years than compared to other professions. Younger people are not entering the profession with the same pace of say, twenty or thirty years ago. Too many other alternative professions exist and the “care” calling just doesn’t appear to be as strong as it once was. I also know too many nurses of parent-age or slightly older that no longer advocate for their children or grandchildren to enter nursing. Being in a family of nurses (my mom, my aunt, my wife, my daughter, etc.), nursing was almost the family profession in some regards and thought highly of as a noble calling and a great career. Here’s a quick snapshot at the demographics, albeit a couple of years old:

A recent report from the National Council of the State Boards of Nursing highlights the negative trend of supply in nursing. The report illustrates a major forward problem in terms of the supply of nurses. According to this report, 100,000 nurses left the workforce during the pandemic. Of a total workforce of 4.5 million nurses, 900,000 are projected to leave the profession by 2027 – four years from now. What’s most concerning is the profession negativity among nurses with less than 10 years of experience. This lack of regard and dissatisfaction with the profession spills over into their cohorts/peer groups, painting nursing as a less than desirable career.

Image and positivity among professionals within any vocation is a key recruitment and retention factor. For a parallel, look at what has happened to police officers and law enforcement. The negativity and disdain for policing that has occurred over the past three years primarily, has driven large numbers of officers away from police work. Concurrently, recruiting new officer candidates has become a major challenge. Nursing is seeing a similar, though not as pronounced, trend. The report and data observation is here:

Digging a bit deeper, I looked specifically at senior living and long-term care. While most other health care sectors have recovered for the most part, hospital and senior living, direct care have continued to struggle. Long-term care bedside nursing has struggled to recover the most, not that it was super staff healthy prior to the pandemic. According to the American Health Care Association (AHCA), an industry trade association, long-term care is 400,000 workers short of demand and the rate is climbing. Per AHCA, 90% of SNFs report being understaffed, 50% severely understaffed, and 98% report hiring is problematic. The result of this staffing crisis is 60% of facilities are reducing census due to lack of staff. A study from the University of California, San Francisco projects that the long-term care/senior living industry will be short 2.5 million workers by 2030. NOTE: CMS and the Biden Administration are proceeding on developing required, mandatory staffing levels in SNFs, in spite of this information. The reference article is here:

What we can glean from literature, nursing professional organizations, nursing unions, and providers is a rather bleak picture of an industry problem that seems to be getting worse, not better. Fixes will require a whole of industry, profession and government approach. Policy makers are definitely going to have to develop a different mindset regarding the work of nurses in nursing homes and how overbearing regulations and enforcement actions don’t improve patient care but do drive nurses from the industry. Listening and reading, what nurses say about why they won’t work in LTC or are leaving their LTC jobs is summarized below.

  • Working conditions – short staffed, short supplies, outdated equipment and environments
  • Pay and benefits not par with other nursing jobs
  • Turnover, especially management
  • Bad management
  • Paperwork burden
  • Negative surveyors and regulations – focus on paper compliance, not patient care
  • Mandatory overtime
  • Lack of support systems internally
  • Lack of training
  • Difficult patients and families – unrealistic about care demands
  • Negativity of the industry.

Solutions? My vantage point encompassing thirty plus years in health care and senior living says we nationally, need a two-prong approach. First, we need to ramp supply. Make nursing a cool and rewarding profession and easy and inexpensive or free to become a nurse. Second, obliterate the foolish impediments to job satisfaction for nurses. Reimbursement in LTC is atrociously low and unable to seriously sustain needed environmental updates and improve comp opportunities for nurses. Pay is not the sole issue, but it is an issue. Likewise, regulations and heavy-handed enforcement is anathema to attracting and retaining good nurses and especially, good nursing leaders. I lost track of how many RN managers and Directors of Nursing I know that have left their jobs because of regulatory foolishness, inept surveyors, and illogical citations. Paper compliance and the amount of time devoted to the same versus patient care is a huge dissatisfier and an equally huge trigger to exit long-term care. A final reference: