The tool uses existing evidence to form recommendations for staffing ratios in long-term care, acute and ambulatory care settings. All of the recommendations are based on key risk factors.

“We are excited to provide this tool to the infection prevention field,” Patricia Jackson, RN, president of APIC, said in a statement. “APIC members have been asking for a resource to help quantify staffing needs for years, and now we can begin to deliver on that promise. With member input, we will be able to provide a robust, accurate staffing tool that will help IP leaders make the case for adequate staff and resources to protect patients.”

The introductory version of the staffing calculator is an “exploratory approach,” APIC says. That is, it’s intended to provide a basic calculation of staffing needs and will collect data that can be used for creating a more rigorous algorithm in the future. 

Data gathered from healthcare facilities that use the tool will be utilized to update it so the tool improves over time. In the next year, an updated version will be released to reflect the accumulated data. In addition to updating the tool as it rolls out, APIC said that it will produce annual reports summarizing data to drive deeper insights into its effectiveness.

The news comes as more organizations are hiring chief infection prevention officers (CIPOs). An article published Dec. 7 in Infection Control Today shared details on this executive role that supports operational positions through the lens of preventing infection.

A recent survey found there’s been 1,400% percent growth in the number of nurses transitioning using the gig models, the article said. An on-demand nurse is similar to a travel nurse but has more flexibility; they don’t necessarily travel for an assignment.

CareRev, Clipboard Health, IntelyCare, Kare, Nursa and ShiftKey are just a few platforms that try to match demand for nurses with supply of nurses, the article started. The platforms let nurses take temporary positions and move on to new opportunities. The nurses often work as contractors, so they don’t get traditional employee benefits. Depending on how they’re classified as workers, the nurses lose some worker protections like minimum wage guarantees and overtime pay. The nurses also may face inequalities, as women and people of color make up a large portion of nurses.

The platforms also can create imbalances when it comes to staffing nurses. That’s because some of the on-demand nurses may opt for the higher-paying shifts, leaving lesser-paying shifts uncovered. Also, having a different rotation of nurses could affect clinical care consistency. Nurses may care more about the money than providing quality care, according to the article. 

Businesses need to be careful about how they classify workers to prevent legal issues, rising costs, and to protect their reputations, the article reported. Healthcare facilities and the nursing staffing platforms have to be watched closely. Misclassifying nurses can create a host of issues. Plus, healthcare laws differ from state to state, which could impact issues for nurses, facilities and the platforms. 

“Travel nurses already have access to the benefits provided by these apps, including the potential for union membership,” the article stated. “Yet, not all health care facilities extend these benefits universally, often requiring full-time employees to sign non-compete agreements to deter them from seeking better-paying opportunities elsewhere.”

These platforms are different from those in other industries due to the high level of regulations affecting the healthcare field. That means there are more opportunities for legal disputes between the parties that use them. 

“The amalgamation of technology, gig economy and healthcare via on-demand nursing platforms presents opportunities such as enhanced flexibility and reduced burnout potential,” the article said. “Despite these advantages, concerns around worker status, legal implications, and job equity arise, demanding careful consideration.”

The news comes as nursing homes face a proposed federal staffing mandate, which also could affect assisted living providers.

The findings were published in the May issue of the Journal of the American Medical Directors Association by a European-based research team. Researchers interviewed about two dozen physician and nurse practitioners in nursing homes about their interprofessional communication — good and bad.  

Researchers found that physicians often struggled to know the exact size and structure of their care team — citing staffing shortages as a main cause — which limited the time they had to talk with staff. The lack of time also was believed to cause nursing staff to forget or get diverted from following up physician’s orders, which caused frustration and less collaboration. 

“Temporary workers to fill in vacancies would complicate communication because they would not know the residents, the care team and the physician. Temporary workers would not usually communicate with the physician,” investigators wrote. “Also, they did not write reports when they were not familiar with the electronic record or were not authorized to access it.”

Investigators also found that physicians had difficulty talking with staff about residents’ care needs because staff couldn’t recognize or explain what the exact problem was. 

“Usually the nurses with more education communicated with the physicians directly. However, they may have heard about changing resident needs second-hand,” report authors said. 

Researchers said the findings stressed the importance of consistent and ongoing communication and collaboration between the two groups. They concluded that “investing in relationships and educating nursing staff pay off when staff can be retained and can also help reduce staff turnover.”

Some problems are so pervasive that even well-intentioned efforts to solve them feel overwhelming and inadequate. The staffing crisis is one of them. Workforce shortages jeopardize the health and safety of both long-term care residents and the staff who care for them. Staffing challenges are intertwined with long-standing issues, including wage levels and stigma, which are exacerbated by incredibly difficult working conditions created by the COVID-19 pandemic. 

The Biden-Harris administration has announced plans to “ensure that every nursing home provides a sufficient number of staff who are adequately trained to provide high-quality care…”, and described reforms powered by many sticks with just a few carrots to help. In this third installment of the Advancing Excellence Policy Series, Board member Tracey Moorhead and Board Chair Barbara Bowers reflect on the announcement. They describe some of the nuances that make staffing problems so pervasive and share additional recommendations for policymakers to make nursing homes better places to live and work.

We welcome you to use this content and reference our complete set of recommendations to help promote change.

–Theresa Schmidt, for Advancing Excellence

Late last month, President Biden announced a set of reforms aimed at improving the safety and quality of nursing home care, including establishing a minimum nursing home staffing requirement. The proposal notes that CMS will conduct research to determine the level and type of staffing needed to ensure safe and quality care and will issue proposed rules within one year.

The Administration’s focus on the need for staffing reform presents a long-awaited opportunity to make lasting, meaningful change, but any reforms must recognize and address factors that have caused current staffing shortfalls while also establishing realistic goals. Absent significant payment reforms directly focused on resolving staffing challenges, PALTC providers will continue to struggle in their efforts to recruit and retain staff.

We have long known that insufficient staffing jeopardizes residents’ quality of life and quality of care and negatively impacts clinical outcomes through delays in care and the inability of staff to provide care that is responsive to resident preferences. Staffing shortages are tied to difficulties recruiting and retaining qualified staff that are also well known to post-acute and long-term care providers.

Nationally, the average annual turnover for CNAs is 80% (or higher) in long-term care settings, while average nurse turnover rates consistently exceed 50%. Staff turnover is also closely associated with increased hospitalization, poorer outcomes, and increased cost. Higher rates of staff turnover have also been linked to greater likelihood of infection control citations.

The staffing crisis has a variety of causes. Compared to hospital staff, registered nurses and nursing assistants working in long-term care settings have lower wages. Nurses also frequently lack access to high-quality training programs, such as residency programs, which have been shown to improve both retention and quality of care. Because working in a nursing home compares so unfavorably to working in a hospital, this contributes to challenges recruiting and retaining advanced practice nurses and registered nurses.

The COVID-19 pandemic exacerbated staffing challenges and raised awareness among both members of the public and policymakers about the impact of staff shortages on care quality. In the early waves of COVID-19, CNAs were celebrated as the “unsung heroes” of long-term care. But as the pandemic progressed, CNAs who worked in more than one nursing home were blamed for spreading the virus. This was a necessity for many CNAs, however, whose poverty level wages required them to work multiple jobs in multiple nursing homes. One in three CNAs qualify for public benefits, and 42% are without health insurance, often due to an inability to afford the employee portion of plans offered by their employers. 

Recruiting nurses and CNAs to replace those who have left during the pandemic is increasingly difficult and expensive, requiring costly marketing and staff replacement programs. Communities may also find it challenging to recruit and retain qualified CNAs because of poor working conditions, lack of advancement opportunities, insufficient training, and lack of a broader U.S. culture that values and explicitly acknowledges their work. Research suggests that improving the work environment for both CNAs and nurses may lead to both improved retention and improved care quality.

Recruitment and retention efforts are also undermined by the stigmas associated with caring for older adults. Common perceptions that nursing homes are undesirable places to live and work persist and are compounded by media coverage and policy mandates impacting providers. Stigmas may be an especially powerful deterrent for students who believe working in this environment is less prestigious than working in acute care. 

Minimum staffing requirements alone will not solve the problems of rapidly rising wages in competing employment sectors, and existing payment models limit the ability of providers to improve wages and working conditions. Reimbursement rates for Medicaid, in particular, contribute to the ongoing lack of parity with competing employment sectors in wages and working conditions. The Administration described their intention to provide a template encouraging states to tie nursing home Medicaid reimbursement to wages and benefits, but current rates only cover 70-80% of the actual cost of care. Increases in public funding for nursing homes would help fill this gap, but must be coupled with robust transparency and accountability measures to ensure that the funds go to staff wages and resident care.

The Advancing Excellence in LTC Collaborative, in an Open Letter to the Biden-Harris Administration, advocated for increased support and reimbursement to improve compensation, benefits, and educational opportunities for staff (see Figure 1).

Additional recommendations include:

• Offer incentives, or directly support increased wage. Promote wage parity with hospital and other post-acute care settings for skilled nursing staff, including CNAs, through wage pass throughs, state pay for performance programs, and other incentives. 
• Consider including an element related to environment and workplace quality in a nursing home quality program. Recommend a minimum level of health insurance benefits offered by long-term care employers. 
• Develop educational content and modes of delivery for nursing home staff development, including person-centered care principles and competency-based professional leveling criteria for staff. Use CMP funds to support training programs. Evaluate the alignment between available training programs and the training needs of skilled nursing staff, including CNAs. 
• Incentivize meeting training thresholds. Establish training thresholds and develop a mechanism to tie these thresholds to reimbursement increases. Include meeting training thresholds in survey criteria. 

We believe that by pursuing and supporting these recommendations, policymakers can help make long-term care communities better places to work for staff, and sufficient staffing will also make them better places to live for residents and achieve the safety and quality improvements envisioned in President Biden’s proposals. 

Tracey Moorhead, MA, is President and CEO of the American Association of Post-Acute Care Nursing (AAPACN). She serves on the board of the Advancing Excellence in Tong Term Care Collaborative.

Barbara Bowers, RN, FAAN, is the current chair of the Advancing Excellence in Long Term Care Collaborative and is Professor Emerita at The University of Wisconsin-Madison, School of Nursing.

Theresa Schmidt, MA, was the 2021 Secretary of Advancing Excellence and has served on the board since 2014. In this role, she led the development of the open letter to the Biden Administration. She is a Vice President at Discern Health, part of Real Chemistry. 

The Advancing Excellence in Long-Term Care Collaborative is a not-for-profit entity that creates a forum for organizations and individuals committed to the needs of long-term care residents and staff to discuss policies that affect these vulnerable populations.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

In 2020, the World Health Organization (WHO) and the American Nurses Association (ANA) joined forces to celebrate nurses with the International Year of the Nurse and Midwife.

Originally created to honor the 200th anniversary of Florence Nightingale’s birth and to elevate the critical role nurses play in transforming healthcare around the globe, the Year of the Nurse took on new meaning during the COVID-19 pandemic as the visibility and appreciation for all that nurses do rose to new levels. 

In a year designated to honor and uplift nurses, too many nurses were instead placed in unimaginable circumstances, with nearly 80% of registered nurses saying the pandemic strained staffing in their unit to “unsafe levels.” WHO and ANA even extended the Year of the Nurse observance into 2021 to bring more attention to nurses’ unrelenting bravery during the crisis. 

But as 2021 and the Year of the Nurse have ended, healthcare leaders are no closer to addressing the rising nursing shortage, which has threatened the industry for decades but is now reaching record numbers. Experts predict an estimated shortage of 1.1 million nurses this year.

While nurses have long been overworked and undervalued, on the heels of COVID-19 and as more nurses reach retirement age or move away from patient care each year, the urgency to improve the situation has never been greater. Without more concerted efforts here, healthcare employers will continue to lose nursing employees — to vaccine mandates, burnout and poor workplace culture, among other reasons. 

As a former nurse myself, I’ve seen the toll that labor issues can take on existing staff. If healthcare organizations are going to have any chance at correcting the issue in the years to come, prioritizing a few key recruitment strategies will be mission critical in order to attract the best nursing talent and support that talent once hired so they can ultimately provide the best care to our communities. 

Expand the face of nursing 

Women have dominated the nursing profession throughout history, and that’s still true today, with females representing 91% of nurses. But this actually opens up some significant opportunities for healthcare employers to expand beyond their typical candidate pools. Healthcare employers need to fill their pipelines with a wider and more diverse group of applicants and demographics. 

Currently, about 50% of all employed Americans say they’re looking for a career change, with nearly a third hoping to switch industries altogether. With so many people thinking about changing careers, healthcare leaders have a huge opportunity to promote job openings and show these new applicants that healthcare is a field in which they can grow for many years to come. 

When it comes to current employees, leaders need to invest in upskilling and educating around the different careers possible across the industry. There’s also a lot of opportunity to recruit for hourly caregiver roles that don’t require extensive education, but with the right training, could offer employees a foot in the door for more skilled, long-term careers in healthcare. 

Reflect diversity in management 

Even with the highest proportion of women in addition to being one of the most racially diverse professions in healthcare, nursing doesn’t reflect the same diversity in its management roles — 55% of healthcare system leaders are white men.

The best thing current leaders can do to encourage more diversity in management is to support and promote diverse members of their existing staff. When diversity is reflected in leadership, those leaders are much more likely to establish genuine connections with current and prospective employees.

Ensuring similarities in the demographics of frontline workers and management also helps to foster goodwill across staff, which can help employees feel more comfortable to share feedback or concerns, and in turn, boosts employee retention. 

Arm nurses with burnout prevention resources 

Over three-quarters of American healthcare workers report feeling exhausted, burnt out and overwhelmed. Skilled nursing staff in particular are often reported to have higher burnout rates than hospital staff.

And after such an unprecedented time in history, healthcare employers have an increasing responsibility to support their nurses — from helping to create a safe workplace environment, offering flexible mental health days, ensuring seamless shift changes, and offering on-site or virtual Employee Assistance Programs. 

Bring back joy, passion and purpose to the profession 

Improving nurse staffing depends greatly on reenergizing current employees and helping them regain a passion for their work. Healthcare employers can help remove the various obstacles preventing today’s nurses from enjoying their work more by offering flexible benefits, recognizing and supporting their hard work and long hours, and getting to know more about their individual and professional goals. All healthcare workers have a drive and a sense of purpose, and by offering them real support, you’re honoring their purpose and making your workplace more welcoming for everyone. 

Living and working at the intersection of health, education and people, nurses have been deeply and unequally impacted by the pandemic. The decade ahead will test the nation’s nearly 6 million nurses in new and complex ways. It will demand a stronger, more diversified nursing workforce that is prepared to provide care and promote health and well-being among nurses, individuals, and communities. 

Pritma Chattha is a Yale-educated, doctorally-prepared nurse executive with 18 years of experience caring for patients at the bedside and in the boardroom. She is the VP of Healthcare Innovation at Apploi, a recruiting, onboarding, and credential management software company serving healthcare organizations. Chattha and her team are on a mission to modernize and speed up healthcare hiring while helping facilities reduce turnover and retain the best staff.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Long-term care providers EmpRes Healthcare and Pennant Healthcare are partners in the externship program with the UW School of Nursing. The state is funding the program through a $167,000 grant, Fox13 Seattle reported.

Connecting with an academic institution that has evidence-based practices will help Pennant in its mission to provide dignified, quality care to its residents, Mindy Schaffner, Ph.D., MSN, CNS, RN, program facilitator at Pennant, told the news outlet. 

“I think most of all nurses that work in long-term care absolutely have to understand and want to care for people whose rehabilitation for their illness may take some time,” she said.

For its part, EmpRes will pair each student with a mentor, according to director of compliance Kristin Bolos, RN. The students, who have an interest in geriatrics, will not only “learn what our culture is and what long-term care is,” but will practice their skills while helping a “very tired workforce,” she said.

The plan is to expand the externship program to other universities and long-term care facilities around the state in the near future.

U.S. nursing homes and other residential care facilities have lost about 380,000 workers since the start of the COVID-19 pandemic in February 2020, McKnight’s Long-Term Care News has reported. And the shortages are expected to get even worse, according to the National Investment Center for Seniors Housing & Care.

The full story can be found here.

Nursing assistants worldwide have ranked shoulders in the top three body parts at high risk of work-related injury, the researchers said. To determine what leads to these potentially debilitating musculoskeletal problems, they recruited 440 workers from 47 Hong Kong nursing homes to answer validated questionnaires on the subject.

Participants responded to queries about their perceived physical exertion, workstyle, ergonomic and manual handling knowledge, and numerous additional work-related factors.

Fully 53% of the participants reported experiencing work-related musculoskeletal symptoms in their shoulders. 

When results were adjusted for age and gender, the three main predictors stood out, reported first author Prof. Kin Cheung and colleagues from the School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong. 

Efforts should be made to integrate “workstyle interventions” into lifestyle physical activity training for these workers, Cheung and colleagues stated.

“Redesigning jobs with more breaks and reducing the work demand, and introducing multidisciplinary exercise programs, should be explored further to improve workstyle behaviors and enhance the musculoskeletal health of nursing assistants,” the authors concluded. 

The study was published online in the journal PeerJ.

Per the guidance, routine testing of staff correlates with the positivity rate in the county over the past week. If it is below 5%, staff should be tested once a month. If the positivity rate is between 5% and 10%, staff should be tested once a week. And if the positivity rate is over 10%, staff should be tested twice a week, according to the guidance. 

Beginning Friday, a website will provide county-level positivity rates. (See the section on the website titled “COVID-19 Testing,” according to the guidance.) 

 Because of the importance placed on the level of COVID-19 in the community, “facility staff, likely the infection preventionist, should be monitoring this website so he or she will know the frequency for routine testing,” Amy Stewart, MSN, RN, vice president of education and certification strategy for the American Association of Post-Acute Nursing, told McKnight’s.

Nursing homes also will be required to test staff and residents if any have symptoms of COVID-19 and if there are any new cases in the facility, according to the guidance. It does not recommend routine testing of residents unless they leave the facility routinely.

Access to testing key

The guidance highlights the importance of point-of-care testing devices or access to a laboratory that can ensure quick turnaround times for testing, Stewart noted.

“Facility leaders need to ensure they are using a POC testing device and that they have sufficient testing supplies in the event that there is a community outbreak and the testing frequency increases greatly,” she said. “If they do not have a POC testing device, they should have a laboratory that they work with who can ensure a 48-hour turnaround time for test results.”

Providers must note their efforts to obtain testing in the event that immediate action is not possible due to slow lab turnaround times or other factors, she noted.

“Document that the ‘XYZ laboratory indicated they could have COVID testing results within 48 hours but for seven out of 99 residents tested, the results took five days,’” she said as a hypothetical example.

Retesting rates, peer pressure

The guidance offers prescriptive testing measures in the event there is a new COVID-19 case. Upon discovery of a new case of COVID-19 in any staff or resident, “all staff and residents should be tested, and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result.”

Stewart said the new guidance makes it critical that staff come forward if they have symptoms.

“Some staff may ignore or downplay potential symptoms, so it is really important that staff and residents feel safe to come forward with symptoms and those symptoms are taken seriously every time,” she said. “This helps ensure that COVID doesn’t enter or spread in your facility.”

The guidance also updates the COVID-19 Focused Survey for Nursing Homes.

“Facility staff should review the changes made to this form because this is what surveyors will be using to ensure facility compliance,” Stewart said.

And she stressed the importance of examining state and local requirements for testing and reporting as these, too, must be followed.

“Many states use emergency room trends as a way to pick up community activity,” she said.

She offered this link to help identify emergency room visits of patients with COVID symptoms.

1 – Experts agree that having a well thought-out formulary is the first step to improving outcomes and saving money.

“The next step is to make sure that all the staff understands how and when to use each of the formulary products. Staff education is more than just telling them what to do,” says Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA, the senior vice president of clinical service, Medline Advanced Wound Care Sales.

2 – Falconio-West says it’s “mandatory” to know the patient/resident’s goals.

“If the treatment goals are palliative vs. healing, the approach to care and the actual treatment could be very different,” she notes.

3 – The use of the formulary must be evaluated. Falconio-West reverts to the “simple nursing process — assess, plan, implement and evaluate” to make sure nurses are thinking critically.

“Change (products) as needed if there is an issue, but not just because someone prefers another brand,” or because it worked for a different person, or at a previous time, she says. Each resident must be assessed as an individual.

4 – Experts also stress evaluating the overall cost of a wound care product. If a treatment is cheaper but requires much more labor, it’s possible the “true” cost is high.

Keep an eye out for “clinically effective and cost-effective brands” as opposed to “clinically effective premium brands,” adds Valerie Johnson, marketing manager, advanced wound care division, MediPurpose.

5 – Falconio-West also calls for providers to rely on the “common sense factor” when evaluating cost.

“I am the first to say, ‘If it isn’t broken, don’t fix it,’” she says. “But it is also very important to realize that if it is broken — or not progressing toward closure, in this instance — then fix it.”

6 – Eliminate products from the formulary if they have duplicate functions, experts says.

“This helps to reduce waste and confusion,” explains Elaine McGowan, BSN, RN, CWCN, DAPWCA, vice president of clinical affairs for Dermarite.

She also recommends providing simple, formulary-based reference guides on every treatment cart and unit, which will help staff use appropriate products properly.

7 – Ongoing education of both nursing aides and licensed nurses is vital, McGowan feels. Aides should be regularly reminded what is on the formulary, how it is best used and when they should consult licensed nursing personnel.

Modifying the topical management as a wound progresses is also important.

“Rarely does one product suffice from the outset of treatment to wound closure,” McGowan notes.

8 – The prevention of wounds that can occur or be exacerbated by incontinence should be a “team” activity, says Bill Lampe, PT, DPT, MS, a clinical director at SCA Americas.

“[Staff should] communicate with each other not only their daily findings, but how they are proactively keeping their residents from a higher risk of skin-related issues,” he says. 

9 – When it comes to 

hands-on care advice, practices such as minimizing taped attached directly to skin can bring big benefits, says Sharon Hamilton, RH, MS, a clinical consultant for Briggs Healthcare.

“Generally, try to put tape on tape as much as possible,” she advises for dressing applications such as those with PICC lines.

10 – Regarding wound product use, it always pays to keep up on the latest developments.

For example, some items now have dressings with a minimally adherent contact layer, which can be a big benefit, says Gayle Jameson, BSN, RN, CWON, CWS, FACCWS, director of clinical nursing for Devon Medical Products. Quieter, lighter products that have features such as rechargeable batteries also help, she adds. 

Mistakes to avoid

 – Allowing staff to not adhere closely to your formulary.

 – Not having a well thought-out and continually reviewed formulary.

 – Not supplying ongoing education for all nursing staff members on products, practices and other features.

The study involved nearly 950 residents in U.S. and Canadian nursing homes. They were at moderate or high risk for pressure ulcers, based on the Braden Scale. All were given a high-density foam support surface and were turned at two-, three- or four-hour intervals.

After three weeks, the incidence of pressure ulcers was the same for all three groups, the researchers found. This was surprising because the moderate-risk group was “significantly different” than the high-risk group with regard to eating and brief changes, they wrote. They also found that the overall pressure ulcer incidence was low (2%). 

“Data suggest that the combination of support surface, repositioning, and documentation were successful in preventing ulcers in the moderate- and high-risk groups,” said the authors, who were based in Utah, Toronto and Texas. 

Consistent documentation also is important, as that might have reminded certified nursing assistants to elevate heels, work on toileting and continence, and engage in other preventive measures. The results also suggest that facilities should consider transitioning to high-density foam mattresses, the researchers stated. 

Findings were published in the October issue of the Journal of the American Geriatrics Society.