Retention and Resilience of Nursing Home Staff during the COVID-19 Pandemic: Voices from the Frontline

Introduction

The nursing home (NH) industry has experienced a 13% drop in employment over the course of the pandemic¹–worse than any other healthcare sector–and NHs across the country continue to face dire staffing shortages with increased reliance on agency staff.² Despite challenging working conditions and public blame, many NH staff have continued in their roles.^3,4 This study sought to elucidate contributors to staff retention and resilience through interviews with frontline NH staff who worked two or more years during the pandemic.

Methods:

We developed an interview guide and conducted semi-structured interviews by telephone with direct-care NH staff. Interview questions were open-ended and focused on reasons for continuing work, support from leadership, workplace policies, and recommendations for retaining and supporting staff. Data were analyzed using the Framework Method, a form of thematic analysis, and a blended inductive and deductive coding approach that relied on the Quality Health Outcomes Model.⁵ The study was approved by Advarra IRB. Details of the methods are included in an Appendix.

Results:

We conducted interviews with twenty participants from seven states, including seven certified nursing assistants, eight licensed practical nurses, and five registered nurses. Nineteen (95%) were female, twelve (60%) were White, six (30%) were Black, seventeen (85%) had six or more years of experience, and eleven (55%) worked the day shift. Eight (40%) were 21–39 years old, and eight (40%) were 40–59 years old. Fourteen participants (70%) intended to be in their current position in one year.

Twelve themes related to staff retention were identified across three framework domains (staff-level characteristics, interventions to retain staff, and modifiable organizational characteristics). Staff characteristics associated with retention included a strong commitment to nursing, as well as traits of adaptability and empathy. Organizational characteristics associated with retention included supportive leadership and staff empowerment practices, as well as teamwork and interprofessionalism. Additionally, we identified several interventions to retain staff, such as on-site mental health professionals, flexible scheduling for staff with children, opportunities for career advancement, equitable pay, and staffing levels that align with care needs.

Discussion:

In this qualitative study of NH staff resilience, eight of the twelve themes identified involved modifiable organizational characteristics and interventions that could be implemented by leadership to support and retain NH staff. We discuss these according to actionability (Table 1).

Table 1:

Themes Related to Nursing Home Staff Retention According to Degree of Actionability

Degree of Actionability	Theme	Example Quotes
Lower Resource Interventions	Verbal encouragement and transparent communication from leadership	“The verbal encouragement was helpful… They were very supportive through it all. You don’t usually hear that you do a good job. But during the pandemic, they made sure we knew we were appreciated.” Participant 4, CNA
	Staff engagement in facility-level decision making	“It [plans/policies from administration] might be realistic to them, but not to the people doing the cares. It’d be better if those plans were made with insights and perspectives from staff members doing the cares.” Participant 3, LPN
	Physical presence of leaders	“She [the CEO] had a physical presence, and it was nice to see her and hear her encouragement … It was helpful to see her and know that we had someone.” Participant 20, RN
Moderate Resource Interventions	On-site support from mental health professionals	“They had counselors who came and talked to us and told us things would be okay. I did find it helpful to talk to someone. With the one-on-one [sessions], you can really express yourself and really cry if you want to cry. I did my share of crying.” Participant 9, CNA
		“We offer all of our patients psychologists, but this isn’t offered to the staff … Why not offer their services to us? … Maybe if we had that, there wouldn’t be so much turnover.” Participant 14, RN
	Childcare support	“I was working while also being a single mother. Emotionally, I had my days where I broke down because it was hard … With my job, they helped out with scheduling to accommodate to my children’s school schedule.” Participant 10, CNA
Higher Resource Interventions	Opportunities for education and career advancement	“Every five years, I want to advance my skill set.” Participant 1, LPN
	Equitable pay	“To be honest, CNAs can be paid a whole lot more. We’re overworked and underpaid. We should feel like we’re appreciated more.” Participant 10, CNA
	Equitable staffing levels	“Everyone would love better staffing, but they bring agency staff in and sometimes you’re better off without them … They don’t have the passion there at all … You’re doing your job plus theirs.” Participant 4, CNA

Lower resource interventions included robust leadership practices such as providing transparent communication, a physical presence on the unit, verbal encouragement, and opportunities for direct-care staff to participate in organizational decision making, including the decision of whether to utilize agency staff. Evidence before and during the pandemic suggests that such leadership and empowerment practices are highly valued by CNAs⁶ and associated with greater retention.⁷ Given growing evidence that NH staff felt abandoned during the pandemic⁸, leadership practices such as routinely greeting staff on the floor and asking about their well-being could positively impact retention.

Moderate resource interventions included on-site services from mental health professionals and childcare support. Our findings suggest that offering mental health support via telephone is likely not effective. Instead, leadership could consider deploying trained healthcare professionals from associated healthcare systems or across NH chains to begin to address this enormous, unmet need. Participants also valued support with childcare, which is not surprising given that over 80% of direct-care NH workers in the US are women⁹ with median age of 42 years.¹⁰ Although stipends for childcare or even on-site childcare may be aspirational and require more resources, at minimum NHs should allow flexible scheduling policies that accommodate childcare schedules.

Higher resource interventions included opportunities for education and career advancement, increased wages, and equitable staffing levels. During the pandemic, NH wages have increased by 21%, more than any other healthcare sector, yet serious staff shortages remain.¹ Further wage increases are needed, but may require significant changes to the current CMS payment model to SNFs. Participants also expressed the need for increased staffing. While a few participants commented on the benefits of agency staff to enhance coverage, most participants expressed frustration. Leadership should include direct-care staff in decisions about utilizing agency.

In summary, there is an urgent need to invest in programs to promote staff retention. These programs will have the benefit of reducing staff turnover and reliance on agency staff, which are financially and administratively costly. Comprehensive strategies that encompass multiple interventions are needed to reform NH work environments. Future investigation should consider the cost-effectiveness of these interventions. In the meanwhile, we encourage NH leadership and policymakers to advocate for these interventions in order to empower and retain frontline NH staff.