The Need for Increased RN Staffing in Nursing Homes: A Critical Look at Proposed Regulations

The nursing home staffing crisis highlighted by the COVID-19 pandemic prompts a call to action for higher staffing levels in long-term care facilities to ensure quality care for older adults, sparking debate and proposed reforms to address the shortage of nurses and improve working conditions in these critical settings. 

“Older adults who reside in our nation's nursing homes deserve the best care nursing can offer,” stated a guest editorial published in the Journal of Gerontological Nursing. “The reality, unfortunately, is that although nursing homes are settings that bear our professional name, they are sadly constrained in the delivery of our care.” 

The persistent and wide-spread low nurse staffing levels made even more noticeable amidst the challenges of the COVID-19 pandemic have led to calls for reform and on September 1, 2023, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule entitled, “Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting.”

The proposed rule would set staffing standards for hours per resident day (HPRD) for registered nurses (RNs) and nursing aids (NAs), require an RN to be on-site 24/7, and enhance facility assessment requirements. 

“It is our belief that the proposed rule, specifically the staffing standards, does not go far enough to meet the complex care needs of nursing home residents and more is needed to improve the work environment to attract and retain sufficient numbers of professional nurses,” warned the editorial. Instead, a case was made based on previous research to require more HPRD for RNs, NAs, and licensed practical nurses than the proposed ruling outlines. The authors noted that barriers to increased requirements could be an insufficient workforce. 

The authors addressed other issues within the nursing workforce that must be resolved as well. Nursing homes must address the wage disparity with hospitals to improve recruitment and retention of RNs, who currently receive 15% less compensation. Greater transparency in how funds are spent is needed, as highlighted by concerns raised by members of the House of Representatives. Improving the work environment, as promoted by programs like the American Nurses Credentialing Center's Pathway to Excellence in Long Term Care^®, can lead to a significant return on investment by attracting and retaining dedicated staff committed to quality care.

The profession can address root causes of the RN staffing shortage in nursing homes by integrating geriatric nursing content and experiences into nursing education programs. Nursing home clinical experiences are underutilized for developing complex assessments, care planning, and nursing leadership skills among students. Faculty themselves need preparation in geriatric care delivery models to provide advanced learning opportunities to students. Staff development in quality care for older adults is crucial in combating the stigma of substandard care in nursing homes.

The Teaching Nursing Home Initiative by the Jewish Healthcare Foundation, the Institute for Healthcare Improvement, and the National Hartford Center of Gerontological Nursing Excellence were resources presented that could mitigate problems contributing to RN staffing shortages in nursing homes.

“The ‘health’ of nursing homes is important to all nurses,” wrote the authors. “A sufficient number of well-prepared RNs in well-performing nursing homes helps ensure quality transitions across the health care continuum and has the potential to lower the cost of health care.” 

Reference 

Kolanowski A, Bowers B, Mueller C, et al. RN staffing shortages in nursing homes: Nursing is part of the solution. Journal of Gerontological Nursing. 2024;50(1):3–5. doi:10.3928/00989134-20231121-01