Skilled nursing facility staffing shortages: Sources, strategies, and impacts on staff who stayed

Abstract

Objective

To examine skilled nursing facility (SNF) staffing shortages across job roles during the COVID‐19 pandemic. We aimed to capture the perspectives of leaders on the breadth of staffing shortages and their implications on staff that stayed throughout the pandemic in order to provide recommendations for policies and practices used to strengthen the SNF workforce moving forward.

Study Setting and Design

For this qualitative study, we engaged a purposive national sample of SNF leaders (n = 94) in one‐on‐one interviews between January 2021 and December 2022.

Data Source and Analytic Sample

Using purposive sampling (i.e., Centers for Medicare & Medicaid quality rating, region, ownership) to capture variation in SNF organizations, we conducted in‐depth, semi‐structured qualitative interviews, guided a priori by the Institute of Medicine's Model of Healthcare System Framework. Interviews were conducted via phone, audio‐recorded, and transcribed. Rigorous rapid qualitative analysis was used to identify emergent themes, patterns, and relationships.

Principal Findings

SNF leaders consistently described staffing shortages spanning all job roles, including direct care (e.g., activities, nursing, social services), support services (e.g., laundry, food, environmental services), administrative staff, and leadership. Ascribed sources of shortages were multidimensional (e.g., competing salaries, family caregiving needs, burnout). The impact of shortages was felt by all staff that stayed. In addition to existing job duties, those remaining staff experienced re‐distribution of essential day‐to‐day operational tasks (e.g., laundry) and allocation of new COVID‐19 pandemic‐related activities (e.g., screening). Cross‐training was used to cover a wide range of job duties, including patient care.

Conclusions

Policies are needed to support SNF staff across roles beyond direct care staff. These policies must address the system‐wide drivers perpetuating staffing shortages (i.e., pay differentials, burnout) and leverage strategies (i.e., cross‐training, job role flexibility) that emerged from the pandemic to ensure a sustainable SNF workforce that can meet patient needs.

What is known on this topic

• Prior evidence has quantified skilled nursing facility (SNF) nursing and rehabilitation staffing shortages during the pandemic and described the impact on care delivery.

• Qualitative evidence has highlighted how SNFs addressed nursing‐related staffing challenges during the COVID‐19 pandemic, such as overtime, cross‐training staff, and use of agency staff.

• Yet, prior research has not examined whether SNF leaders perceive shortages more broadly across their staff, and if so, for what roles, or to what they attribute these shortages.

What this study adds

• SNF leaders (n = 94) described staffing shortages across job roles, driven by external (e.g., higher pay in other sectors, childcare demands, vaccine mandates) and internal (i.e., organizational, staff specific) factors.

• Staff who stayed experienced an increase in job demands (i.e., essential day‐to‐day operational tasks, new COVID‐19 pandemic‐related responsibilities) that exacerbated the strain.

• Policies to support SNF staffing should consider all job roles and address external (e.g., pay differentials) and internal factors (e.g., staff burnout, staff‐centered flexible job roles, professional development).

1. INTRODUCTION

Skilled nursing facilities (SNFs) in the United States care for a varied population including persons admitted for short stays after hospitalization, persons admitted for end‐of‐life care, and residents whose stays extend for years. Meeting the day‐to‐day needs of these populations requires a diverse staff with a wide array of training and skills. ¹ SNF employees include direct care staff (e.g., licensed nurses, certified nursing assistants [CNAs], rehabilitation providers, social workers, dieticians), support staff (e.g., dietary, environmental services), administrative staff (e.g., business office, medical records), and leadership (e.g., Administrator, Director of Nursing, Chief Operating Officer). ² , ³ Direct care staff training and education levels vary widely, from CNAs who can be certified after completing a short training course and must work under a licensed nurse, to rehabilitation therapists who have master's or doctoral degrees. ⁴ Support staff roles are primarily entry‐level positions with no formal education requirements. Despite differences in education and training across staff, collaborative effort of the interdisciplinary team is necessary to deliver high‐quality SNF care.

While staffing challenges have been a long‐standing issue in SNFs, the COVID‐19 pandemic exacerbated them. Prior evidence quantified pandemic‐related SNF nursing and rehabilitation staffing shortages and the impact on care delivery. ⁵ , ⁶ , ⁷ , ⁸ Nursing staff shortages continued long into the pandemic, with nearly 30% of SNFs still reporting shortages, especially for CNAs, in early 2022. ⁹ While therapy staffing declined across the board when the pandemic started, therapy assistant and contract staffing remained especially low in 2022 compared with pre‐pandemic baselines. ⁵ Qualitative evidence captured how SNFs navigated the dynamic policy environment during the pandemic and addressed nursing‐related staffing challenges via overtime, cross‐training staff, increasing staff‐resident ratios, and use of agency staff. ⁶ , ¹⁰ Yet, beyond nursing and rehabilitation, these studies have not adequately examined staff roles such as support staff, which are vital for daily operations, to understand whether SNF leaders perceive shortages more broadly or to what they attribute shortages. As a result, there is limited evidence available to inform evolving policies and practices for addressing the depth and breadth of SNF staffing shortages.

Given the necessity of a wide range of staff to support the needs of all SNF populations, the first step is to understand the breadth of SNF staffing shortages across job roles. Failure to examine SNF leadership perspectives of staffing shortages across job roles will hinder efforts to address system‐wide drivers and support SNFs in their efforts to recover after the COVID‐19 pandemic, proactively limit future shortages, and meet new minimum staffing requirements for CNAs and Registered Nurses (RNs). ¹¹ Therefore, the objective of this study is to examine the breadth of staffing shortages, the sources of the shortages across job roles, and the impact on the staff who stayed during the pandemic. Further, we aim to highlight policies that can target system‐wide drivers that perpetuate SNF staffing shortages.

2. METHODS

2.1. Sampling

We conducted semi‐structured interviews with a purposive sample of SNF leadership between January 2021 and December 2022. These interviews were part of a larger study that intended to examine the impact of post‐acute care payment reform and COVID‐19 pandemic on SNF operations, staffing, and care delivery from multiple perspectives. ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ All aspects of the study protocol were reviewed and approved by the University of Pittsburgh institutional review board.

We used purposive sampling to maximize variation, with respect to SNF quality rating, geographic location using CMS's four region categorization, ownership status (for‐profit vs. nonprofit/governmental), and urban versus rural location. Quality ratings were categorized as high, medium, or low based on the Centers for Medicare & Medicaid Services (CMS) nursing home five‐star quality ratings. ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ SNFs in the high‐quality group had four‐ and five‐star quality ratings. SNFs with a three‐star rating comprised the medium‐quality group and the one‐ and two‐star ratings were classified as low‐quality group. The inclusion of CMS quality ratings, ownership status, and location in the sampling frame was based on substantial evidence that has linked these characteristics to patient outcomes and operations. ¹⁷ , ²² , ²³ , ²⁴ , ²⁵ Further, this sampling frame was designed to ensure representation of a broad range of SNF leader perspectives across the United States and organizational contexts. ¹⁶ , ²⁵

For each eligible SNF that agreed to participate, we sought the perspective of one leader (i.e., Administrator, Assistant Administrator, Chief Operating Officer, Director of Nursing) who could speak to their organization's response to COVID‐19 pandemic. Additional details on the construction of the SNF sampling frame are documented elsewhere. ²⁶

2.2. Interview guides

The interview guides were informed a priori by the Institute of Medicine's Model of Healthcare System Framework ²⁷ to explore SNF operations, staffing, and care delivery, which aligned with the objectives of the parent study. Interview guides were structured to explore two overlapping events: (a) Medicare post‐acute care payment reform and (b) the emergence and evolution of COVID‐19 pandemic. Details of the interview guide development and cognitive interviews process for refining the questions are provided elsewhere. ²⁶ This paper focuses on interview responses addressing pandemic influences on staffing. A systematic process was used to train all interviewers and ensure consistent delivery of interviews per study protocol. ²⁶

2.3. Recruitment and interview procedures

Following our sampling frame, a multimodal recruitment strategy included phone calls, emails, and postal mailing to eligible SNFs. We also constructed a study website to provide more information about the study and the team, which augmented recruitment materials. Finally, we disseminated project summaries via industry organizations (e.g., email blasts, newsletters) to raise awareness of the study. SNF leaders who wanted their facility to be included in the study could not independently initiate engagement, they had to be recruited via our study team in order to comply with the sampling frame. Interviews were conducted via phone, audio‐recorded, transcribed via Otter.ai, and quality checked for accuracy. Interviews lasted an average of 45 min. At the start of the interview, participants were asked to provide information regarding their demographics and job role (e.g., race, ethnicity, tenure in job role). Data were captured via REDCap electronic data capture, which is hosted by the Clinical and Translational Science Institute at the University of Pittsburgh. ²⁸ , ²⁹

2.4. Coding and analysis

Following the methods of Abraham and colleagues, we performed a three‐step rapid qualitative analysis. ³⁰ This method was chosen given the descriptive nature of this study and the need for timely information to guide evolving policy and practices. ³⁰ , ³¹ , ³² Three investigators engaged in an iterative process to develop the coding matrix, which included reviewing transcripts and discussing distinct concepts. The matrix was then used to conduct the thematic analysis of all transcripts. All coders went through a rigorous training program to ensure calibration with the matrix codebook. ²⁶ Processes were implemented to detect codebook deviations and ensure rigor and validity across coders. ²⁶

Analysis examined themes, patterns, and relationships that arose. As new material emerged that was different or unexpected, additional codes were added. ³³ Finally, we used negative case analysis to identify contradictory and/or outlier perspectives to ensure robustness of findings. ³⁴

3. RESULTS

We conducted interviews with 94 SNF leaders. The median time in a leadership position was 4.6 years (7.2 months, 38.8 years) within the qualifying SNF. The sample included for‐profit (48%) and nonprofit or government‐operated SNFs (52%), as well as urban (46.8%) and rural (53.2%) SNFs (Table 1). Below, we describe leaders' perceptions of staffing shortages, the sources of the shortages, and the impact these shortages had on the staff that stayed.

TABLE 1.

SNF leadership demographic and organizational characteristics.

SNF leadership characteristics (n = 94)
Age in years, mean (SD)	47.9 (11.6)
Gender identity, %
Female	53% (n = 50)
Male	46% (n = 43)
Non‐binary or transgender	0
Preferred not to disclose	1% (n = 1)
Race and ethnicity, %
American Indian/Alaskan Native	2.1% (n = 2)
Asian	2.1% (n = 2)
Hispanic or Latino	3.2% (n = 3)
Non‐Hispanic Black or African American	5.3% (n = 5)
Native Hawaiian, Pacific Islander	0
More than one race	1.1% (n = 1)
Non‐Hispanic White	85.1% (n = 80)
Preferred not to disclose	1.1% (n = 1)
Leadership role in the SNF, %
Administrator a	94% (n = 88)
Chief Operating Officer	3% (n = 3)
Director of Nursing	3% (n = 3)
Years in Leadership role in SNF, median (range) b	4.63 (0.6, 38.8)
In leadership role less than 2 years, at time of interview b , %	22% (n = 21)
Highest level of education completed, %
Graduate degree	40% (n = 38)
Bachelor's degree	52% (n = 49)
Associate's degree	5% (n = 5)
High School graduate or equivalent	1% (n = 1)
Preferred not to disclose	1% (n = 1)

SNF organizational characteristics c
Census Region, %
Region 1: Northeast	24.4% (n = 23)
Region 2: Midwest	28.7% (n = 27)
Region 3: South	26.6% (n = 25)
Region 4: West	20.2% (n = 19)
Ownership, %
For‐profit	48.0% (n = 45)
Nonprofit or Government‐operated	52.0% (n = 49)
SNF located in rural area, %	53.2% (n = 50)
Overall 5‐star quality rating, %
Five stars	25.5% (n = 24)
Four stars	28.7% (n = 27)
Three stars	16.0% (n = 15)
Two stars	13.8% (n = 13)
One star	16.0% (n = 15)
Care quality star rating, %
Five stars	20.2% (n = 19)
Four stars	18.1% (n = 17)
Three stars	31.9% (n = 30)
Two stars	22.3% (n = 21)
One star	7.4% (n = 7)
Patient demographics of participating SNFs, mean (SD)
Percent of patients who are dual‐eligible	30.7% (19.3)
Percent of patients who reside in rural regions	53.3% (41.0)
Percent of patients who are American Indian/ Alaskan Native	0
Percent of patients who are Asian or Pacific Islander	0.9% (9.1)
Percent of patients who are non‐Hispanic Black or African American	4.9% (16.7)
Percent of patients who are non‐Hispanic White	88.1% (16.7)
Percent of patients who are Hispanic	1.4% (11.1)

Abbreviations: SD, standard deviation; SNF, skilled nursing facility.

^a Administrator category, included job titles as administrator and center executive director.

^b Time in leadership is restricted to position in participating SNF, it does not include time in prior facilities.

^c Data capturing organizational characteristics were from the 2019 Provider of Services Files, Nursing Home Compare Provider Information files, and Post‐Acute Care and Hospice Provider Utilization and Payment Public Use Files.

3.1. Theme no. 1: Breadth of staffing shortages

SNF leadership consistently described loss of staff coupled with difficulty hiring staff across all job roles during the pandemic. The shortages were described as far‐reaching and included losing administrative and support staff, such as front office employees, housekeeping, laundry, hairdressers, and maintenance services. When commenting on the breadth of unfilled positions, one leader from a medium‐quality SNF noted “We've had quite a few nurses, aides, housekeepers, dietary people, management, staff, leadership, all around, I don't think there's been one department that hasn't been affected [by shortages].” Further, respondents described the loss of dietary service staff, which included staff who prepared the meals as well as those who set up the meal trays, served meals, and washed dishes. “[We] lost a lot of dietary [staff who] left [the industry]” (Leader from low‐quality SNF). Among direct care staff, SNF leadership described shortages in rehabilitation providers, nursing, social services, and activities staff. Finally, leadership described the loss of department heads in nursing and rehabilitation as well as their peer Administrators. “But the burnout, I lost a DON [Director of Nursing] …she just couldn't take it anymore” (Leader from low‐quality SNF).

3.2. Theme no. 2: Drivers of staffing shortages

Figure 1 illustrates the sources of staffing shortages, which are grouped as external environment, internal environment, organizational policies, and staff specific—for which we provide more information below. File S1 provides additional supporting quotes that exemplify these sources of staffing shortages.

FIGURE 1.

Drivers of staffing shortages across skilled nursing facility (SNF) staff job role categories.

3.2.1. Environment: Higher salary

Across job categories, SNF leadership described the external pull of staff toward higher salaries elsewhere. SNF leadership gave examples of support staff, including housekeeping, food service staff, and CNAs leaving to work in other sectors (i.e., grocery stores, fast‐food restaurants) where salaries were higher. “When grocery stores and fast food started paying more, [food services and housekeeping staff] left for those jobs because [they] paid better” (Leader from medium‐quality SNF). This was particularly salient for SNFs in states that raised the state minimum wage. “When state minimum wage increased, [I] had environmental services staff leave to go other places” (Leader from medium‐quality SNF). Beyond housekeeping and food service staff, SNF leadership also described the pull of RNs and licensed practical nurses to other states, healthcare settings (e.g., hospitals, hospice), and/or agency positions that offered higher salaries. “[Nurses] left to travel because [of] how much more money they [could] make” (Leader from medium‐quality SNF).

3.2.2. Environment: Closure of schools and daycare

Across job categories, SNF leadership described staffing challenges that resulted from parents/guardians whose children were required to learn remotely at home early during the pandemic and, later during the pandemic, due to closure of schools and/or daycare due to exposures/outbreaks.

Within the context of the early pandemic, SNF leadership described staff who left their jobs to fulfill family caregiving responsibilities for children who were home due to remote learning. “[One of our] biggest problems were when schools closed, and staff had to stay home to take care of kids” (Leader from medium‐quality SNF). For those staff who stayed through the early phases of the pandemic, the challenges occurred later in the public health emergency when staff were unable to come to work due to unexpected school and daycare closures that sent kids home due to exposure to COVID‐19. “Other barriers [related to] staffing of when families are sick [with COVID‐19], schools and daycares closed [they could not work]” (Leader from medium‐quality SNF).

3.2.3. Environment: COVID‐19 infection control regulations

SNF leadership described three overarching drivers of staff challenges, which arose from efforts to comply with pandemic‐related regulations. First, SNF leadership described having to relieve staff from their positions when staff refused to wear personal protective equipment. “We lost several nurses in the first couple months because they didn't want to wear masks” (Leader from medium‐quality SNF). Further, several SNF leadership described staff quitting because they did not agree with patient quarantine rules and restrictions placed on family visitation. One SNF leader from a low‐quality SNF described, “I had staff just up and quit the day that they found out that we weren't allowing visitors in.” Third, the COVID‐19 exposure regulations, which prevented staff from working for up to 14 days, further exacerbated staffing shortages across job categories. One SNF medium‐quality leader described, “…for 6 weeks [we] did not have therapy [staff], [they were] out for COVID or possible exposure.”

3.2.4. Environment: COVID‐19 vaccine mandate

As the pandemic evolved and vaccines were available, SNF leadership described the next wave of staff exodus, which spanned across staff categories (e.g., front office staff, nursing, hairdressers), as being fueled by the vaccine mandate. “We lost 10% of our work force due to the [vaccine] mandate” (Leader from low‐quality SNF). Across regions and SNF quality performance scores, staff quit instead of getting the vaccine and either refused to apply for an exemption or were not eligible for one. Others applied for a vaccine exemption, but later left due to requirements for additional testing that were part of the exemption protocol. SNF leadership also described the mandate as a barrier to new hires, as some applicants refused to be vaccinated and were not eligible for exemptions. “[Many told me] ‘If I've [got] to take the vaccine, I don't want the job there.’ If anything [this mandate] has had a negative impact [on staffing levels]” (Leader from low‐quality SNF).

3.2.5. Organizational context: Rehabilitation providers

Among SNFs that had a history of sharing their occupational, physical, and speech therapy providers with other SNFs, leadership described staffing challenges due to risk mitigation. SNF leadership described staff having to choose one facility to work in, as they could no longer maintain their pre‐COVID‐19 schedules of caring for patients across multiple facilities. “[We] lost some therapy people to other nursing homes because they couldn't go from building to building [as they did pre‐COVID]” (Leader from medium‐quality SNF). This resulted in a staffing shortage of rehabilitation providers.

3.2.6. Organizational context: Agency staff

There was no consensus on the use of agency staff. Some acknowledged that using agency staff was the only way to keep doors open when staffing levels were dire. “[We are] dependent on agency to care for residents” (Leader from medium‐quality SNF). Among those that used agency staff, some leadership described challenges they experienced, including refusal to work on COVID‐19 units and completing the bare minimum tasks. Further, they described agency staff not having a connection with residents or the community as temporary staff. “You can't create someone that knows our community, but that is not the industry right now” (Leader from high‐quality SNF). Others described going to all lengths to avoid using agencies, including leadership taking on extra shifts to fill gaps.

3.2.7. Staff‐level drivers: Emergence and Evolution of the pandemic within individual SNFs

SNF leadership differentiated between reasons staff left their jobs (a) early in the pandemic versus (b) later in the pandemic. As awareness of COVID‐19 emerged, staff left jobs in the SNF due to fear, (early) retirement, and need to prioritize health of family or themselves due to being immunocompromised. “I had staff just up and quit on the same day that we had our first patient that was positive” (Leader from low‐quality SNF). SNF leadership described dietary, housekeeping, nursing, and maintenance staff leaving for these reasons.

For the staff who stayed through the initial emergence of COVID‐19, leadership described the increased burnout that they witnessed approximately 6 months into the pandemic. They articulated the emotional and physical fatigue that resulted in another round of staff leaving. “We lost good people, not to death. We just lost good people because they'd had enough” (Leader from high‐quality SNF). SNF leadership described the physical strain of wearing personal protective equipment (PPE) all day, ever‐changing policies, the vilification of SNFs in the media, the strain of staffing shortages, the emotional toll of death, and the unknowns of the pandemic.

SNF leadership also described the impact of COVID‐19 on staff health. “I had three staff [that] ended up on vents” (Leader from high‐quality SNF). SNF leadership described staff sick with COVID‐19 that were on permanent disability and not able to return to work. Finally, several SNF leaders articulated the grief staff experienced due to the COVID‐19 deaths of their peers and residents.

3.3. Theme no. 3: Strategies to combat drivers of staffing shortages

Leadership described a wide range of strategies they used to meet patient care needs. As described below, these strategies included leveraging existing staff through reallocation and cross‐training of essential patient care tasks related to (a) non‐nursing job roles and (b) nursing‐related tasks. Finally, leadership highlighted new COVID‐19‐related tasks that had to be distributed across staff.

3.3.1. Cross‐training staff in non‐nursing tasks

Staffing shortages necessitated the reallocation of a wide range of tasks among remaining staff, including food services, housekeeping, laundry, and ancillary tasks. Leadership described thinking out of the box to get tasks done “by taking a team approach to care” (Leader from high‐quality SNF). For example, one leader from a low‐quality SNF described “I couldn't do clinical work, but I could clean the beds, disinfect, you know, serve meals, everybody just had to pitch in.”

Whether staff were senior management, department heads, or administrative staff, SNF leaders described individuals stepping up to fold laundry, wash dishes, pass meal trays, and clean rooms. “If it wasn't for the team's efforts to go above and beyond [to] take care of the residents, pass food trays and things like that. Then, you know, I think care quality would have gone down” (Leader from medium‐quality SNF). Additional supporting quotes are provided in File S2.

3.3.2. Breadth of staff covering nursing staff shortages

Leadership described two strategies for overcoming nursing‐related shortages, including CNA shortage and COVID‐19‐unit staff. SNFs leveraged the CNA‐in‐training waiver and feeding assistant waiver to cross train staff to cover tasks completed by CNAs, such as bathing, transferring, dressing, and feeding. Examples of staff who were cross trained included social services, rehabilitation, and administrative staff (e.g., business office manager). One SNF leader from a low‐quality SNF explained, “We had everyone cross trained, we had activity staff that we cross trained to be CNAs.” Further, individuals in leadership positions with clinical training as nurses reallocated their effort to provide direct patient care, including passing medications and supporting activities of daily living (e.g., bathing, toileting). “[Our] management team provided support to nursing staff and delivered patient care, including Assistant Director of Nursing and Unit managers” (Leader from low‐quality SNF). Further, SNF leaders described nursing leadership stepping in for hard to cover shifts such as nights and weekends, particularly on COVID‐19 units. File S2 provides additional quotes across job roles.

3.3.3. Impact of shortages: distribution of COVID‐19 related tasks

The implementation of COVID‐19 related policies brought on new tasks for SNFs to manage in addition to existing operations. Leadership described a wide range of COVID‐19‐related tasks, including (a) tracking and implementing pandemic reporting and procedural requirements (e.g., screening, testing, 24‐h mandate to call family to report exposure), (b) supporting family–patient/resident communication (e.g., scheduling, coordinating virtual visits), (c) staff taking on role of family and social support for patients and residents, and (d) supporting telehealth visits. SNF leadership described engaging a wide range of SNF staff to support the execution of all these new tasks, from leadership to direct care workers (e.g., activities staff), ancillary staff (e.g., housekeeping), and administrative staff (e.g., marketing staff, receptionist). Further, SNF leadership described the substantial time and resources devoted to these tasks, which often diverted time from the staffs' other job responsibilities. “Social services work doubled over night when the COVID exposure policy was implemented [referencing the requirement to call family within 24 hours of exposure]” (Leader from low‐quality SNF). Additional quotes across job roles that convey these themes are detailed in File S3.

3.3.4. Rethinking task distribution across staff

As the pandemic evolved, SNF leadership described learning from the reallocation of tasks, and “embracing disruptive innovation” (leader from low‐quality SNF). They described using that knowledge to align staff strengths and skills with staff responsibilities and not being constrained to prior approaches to job role construction. “We are now going back and taking a more serious look [at scope of task distribution, staff strengths, and job roles to determine], what is a better format for doing some of these tasks, in order to make better use of the skilled staff that we have” (Leader from high‐quality SNF). One leader from a high‐quality SNF described capitalizing on the organizational skills of the central supply staff member, “[I] moved our central supply person to COVID logistics coordinator [to] organize all testing, vaccines, PPE (personal protective equipment) acquisition and storage.” A leader in a medium‐quality SNF described task reassignment, “if they weren't direct patient care before, they were now if we needed to pull, I mean, we had our essential work, and everyone was assigned different tasks within their trained ability.”

3.4. Theme no. 4: Negative case analysis

A few SNFs described experiences that differed from those above with respect to staffing challenges. Three SNFs, of different care quality star ratings and different regions, described offering voluntary layoffs and/or letting staff go given the drop in census. Another SNF described an initial drop in staff, which then returned to full staffing levels. Finally, there was a small group of SNFs that reported no challenges with respect to staffing levels. These SNFs spanned regions, urban versus rural location, and quality of care rating (File S4).

4. DISCUSSION

The COVID‐19 pandemic accelerated existing staffing challenges in SNFs. ¹ To our knowledge, this is the first national study to report on SNF leadership's perspectives on staffing shortages that spanned all job roles, facility quality ratings, and across geographic regions. This study highlights the multidimensional sources of staffing challenges, in that they included external as well as internal (i.e., organizational, staff specific) drivers of staff shortages. For staff who stayed, they experienced an increase in job demands within an already strained workforce. Based on our study, we discuss four major findings within the context of the current literature and recommend strategies for addressing the multidimensional sources of SNF staff shortages.

First, when considering the environmental drivers of SNF staffing shortages, future policy needs to consider the pull of staff to higher‐salary positions both within and outside healthcare. As highlighted in our interviews, support staff and CNAs left SNFs to work in grocery stores and restaurants or left to work at other healthcare settings with higher pay. The value placed on caring for nursing home residents in society is directly reflected by the salary paid to persons caring for them. When nursing home salaries lag behind fast‐food and grocery stores, it is a clear indication that policy is failing the most vulnerable members of society. For those staff who left the SNF for another healthcare setting with higher salary, there is a need to stop the practice of enhancing staffing levels in one healthcare setting by pulling staff from another, which perpetuates a siloed approach to staffing. Future policy needs to account for salary differences as well as the perceived (or actual) lower risk of working in these other settings. Addressing these external environmental drivers that perpetuated the loss of SNF staff will be especially important in light of the new proposed SNF minimum nurse staffing standards that provide increased pressure to reduce turnover and retain staff.

Second, our results demonstrate the breadth of staffing shortages in SNFs includes all job roles. New proposed minimum staffing standards include RNs and CNAs only, yet our study emphasizes that meeting the needs of SNF patients and long‐stay residents requires a staff who spans across direct care, support, administrative, and leadership roles, not just direct care nursing staff. The results emphasize that workforce policy needs to reconceptualize pathways to careers in healthcare across job roles, beyond nursing, to prevent future staffing shortages and ensure the long‐term viability of the collective workforce. Past research has documented the benefits of career ladders for CNAs ³⁵ , ³⁶ Future research should consider similar approaches to reinforce and sustain the SNF staff infrastructure, across job roles, to foster pathways to SNF careers and prevent future shortages.

Third, building on the findings of this study, more research is needed to examine opportunities for reconceptualizing job roles and related policies. SNF leadership in our study described efforts to match staff expertise and skills with tasks by thinking beyond the traditional job role descriptions. This finding aligns with prior work that found healthcare providers valued meaningful patient‐centered care and the importance of staff‐oriented work environments as an approach to enhancing job satisfaction and reducing staff turnover. ³⁷ Further, our data highlighted the use of COVID‐19 waivers to cross train and reallocate staff (e.g., temporary nurse aide training waiver, feeding assistant waiver). Such efforts that match staff strengths with job tasks should be evaluated to determine the relationship with staff retention and feeling valued as employees.

Fourth, efforts need to be initiated to address the burnout and well‐being of all SNF staff. We found SNF leadership described staff across job roles struggling with burnout as well as physical and cognitive exhaustion, well beyond the crisis moments of outbreaks within the SNF. These findings are consistent with prior work, which focused on nurses and certified nursing assistants. ³⁸ Such an effort will require addressing external, organizational, and individual drivers that have perpetuated burnout. Efforts to achieve this objective must account for the environmental demands that place additional strain on staff as well as organizational efforts to support the health and well‐being of staff. Drawing on past evidence, a comprehensive approach to addressing staff burnout includes individually tailored interventions that address work stress as well as initiatives that promote professional development and staff empowerment. ³⁹ , ⁴⁰ While many of these prior initiatives have focused on physicians, there is a need to evaluate such practices within an SNF context across job roles to ensure that the SNF workforce can be sustained.

4.1. Limitations

Several limitations should be acknowledged. This study reflects SNFs that continued to operate throughout the COVID‐19 pandemic. Thus, these findings do not reflect SNFs that closed. We sought perspectives of individuals in leadership within the SNF who could speak about organizational operations before and during the pandemic. However, given turnover in leadership, some participants were not in the facility for an extended period of time prior to the pandemic or filled leadership positions across multiple facilities. Additionally, the study is limited to leadership and does not capture the voices of the staff who stayed or those who left the SNF. Finally, given the timing of the interviews relative to the emergence of the pandemic, the interviews relied on recall of the interviewee from the early months of the pandemic.

In conclusion, this study identified the multidimensional drivers of staff shortages across job roles in SNFs during the COVID‐19 pandemic and identified the strategies used by SNF leadership to manage staffing challenges. Our study focused on the perspectives of SNF leaders, highlighting the importance of considering the multidimensional drivers that perpetuated an exodus of staff from SNFs. Policies aimed at strengthening the SNF workforce must address (a) higher salaries being offered within and outside healthcare; (b) pathways to careers in healthcare; (c) reconceptualizing job roles; and (d) the burnout and well‐being of the SNF workforce. Only by addressing these drivers can SNF staffing shortages improve.

FUNDING INFORMATION

This study was supported with funding from the National Institute on Aging (AG065371). This study was also supported by resources made available via the Clinical and Translational Science Institute at the University of Pittsburgh (UL1‐TR‐001857). Dr. Falvey was supported by the National Institute on Aging (K76AG074926) during the development of this manuscript.

CONFLICT OF INTEREST STATEMENT

Natalie Leland, Rachel Prusynski, Amanda Shore, Jason Falvey, Tracy Mroz, and Debra Saliba have no conflicts to disclose. Michael Carey discloses that he is a contributor to UpToDate.

Supporting information

Data S1. Supporting information.

Data S2. Supporting information.

Data S3. Supporting information.

Data S4. Supporting information.

Leland NE, Prusynski RA, Shore AD, et al. Skilled nursing facility staffing shortages: Sources, strategies, and impacts on staff who stayed. Health Serv Res. 2024;59(6):e14355. doi: 10.1111/1475-6773.14355