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. 2023 Feb 8;33(Suppl 1):S5–S10. doi: 10.1093/ppar/prac029

Policy Priorities for a Well-Prepared Nursing Home Workforce

Christine Mueller 1,✉, Jasmine L Travers 2
Editor: Brian Kaskie
PMCID: PMC9933699  PMID: 36817185

Workforce issues are at the heart of quality care in nursing homes and are directly related to having sufficient competent staff to care for residents and meet their holistic needs. Researchers have provided extensive evidence identifying workforce factors associated with nursing home quality as well as interventions to address nursing workforce issues (Clarke and Donaldson, 2008). A recent report from the National Academies of Sciences, Engineering and Medicine (2022), The National Imperative to Improve Nursing Home Quality: Honoring our Commitment to Residents, Families and Staff (2022), squarely addresses nursing home workforce issues with nine recommendations. The recommendations of the Committee on the Quality of Care in Nursing Homes (hereafter referred to as the Committee) on workforce are intended to achieve the goal of ensuring a well-prepared, empowered, and appropriately compensated workforce. There are multiple types of nursing home staff in nursing homes fulfilling a variety of direct and indirect care roles for nursing home residents. A distinguishing feature of the variety of roles is that some are required to hold a license (e.g. physical therapist, nurse) and others are not (e.g. nursing assistant, housekeeper). There are no state or federal regulations requiring that nursing home staff have specific geriatric-focused competencies. Even academic degree requirements for key staff, such as directors of nursing, administrators, and social workers, are lacking insofar as they are not specified in regulations for nursing homes. This article focuses on the recommendations related to the education, training, and competencies of all individuals employed in nursing homes and policy strategies to ensure a well-qualified, competent nursing home workforce. Table 1 summarizes the policy recommendations proposed in this article.

Table 1.

Policy Recommendations to Ensure a Competent Nursing Home Workforce

Recommendation Responsible entity
Require the collection of professional education degree data for directors of nursing, nursing home administrators, and social workers, as part of the data collected for Nursing Home Compare. CMS
Conduct research to examine the relationship to quality of nursing home care and factors such as the academic degrees and certifications held by these key personnel as well as their tenure in the role. Academic institutions; policy research organizations
Collect direct care workforce statewide data and centralize the training and certification records of direct care workers noting the data collection infrastructure should be informed by a national minimum dataset on the direct care workforce. CMS and state agencies
Develop competencies required for the various type of personnel working in nursing homes by establishing an ongoing panel of experts. CMS
Develop requirements for ongoing demonstration of competencies for persons employed in nursing homes. CMS
Increase nurse assistant training hours based on the national competencies developed for nursing assistants and the amount of time to demonstrate competence through both didactic and experiential training. CMS and state agencies
Require all direct care staff in nursing homes to have basic training in working with older adults. CMS
Reimburse entry-level training costs so that nursing homes can provide training to nursing assistants and other direct care workers free of charge. CMS and state agencies
Conduct a comprehensive analysis of the AACN competency-based framework for professional nursing education and recommend how the proposed domains, competencies and sub-competencies can be applied to the integration of gerontological nursing in nursing curricula. Gerontological nursing organizations (e.g. GAPNA, NHCGNE; AACN Expert Panel on Aging)
Integrate national competencies for gerontological nursing education into accreditation criteria for undergraduate and graduate nursing programs to ensure all schools have competent faculty in teaching nursing care of older adults. Commission on Collegiate Nursing Education (CCNE)
National League for Nursing Accreditation Commission (NLNAC)
Provide financial incentives to increase the number of geriatric specialists in all health professions and to include specific enhancement of reimbursement for clinical services delivered to older adults by practitioners with a certification of special expertise in geriatrics. CMS and state agencies
Create funded faculty fellowships focusing on teaching in nursing home settings. Academic institutions and foundations
Establish federal and state funding mechanisms to support the development of faculty to teach and lead practicum experiences in nursing homes. Health Resources and Services Administration; state agencies
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Notes: CMS = Centers for Medicare and Medicaid Services; GAPNA = Gerontological Advanced Practice Nurses Association; NHCGNE = National Hartford Center of Gerontological Nursing Excellence; AACN = American Association of Colleges of Nursing.

Workforce issues are at the heart of quality care in nursing homes and are directly related to having sufficient competent staff to care for residents and meet their holistic needs.

Academic Degrees and Certification

Nursing homes are required to have an administrator, director of nursing, medical director, and a social worker. Although each needs to be licensed, the academic degree requirements for the administrator, social worker, and director of nursing can vary. Currently, in 17 states, nursing home administrators do not need to hold a bachelor’s degree (National Association of Long Term Care Administrator Boards, 2021), and no states require a bachelor’s degree for directors of nursing or social workers. For directors of nursing, the majority hold an associate degree in nursing (Olson and Zwygart-Stauffacher, 2008; Trinkoff et al., 2015; Sherman and Touhy, 2017; Palm et al., 2019). Additionally, the responsibilities and associated competencies for directors of nursing are not part of the curriculum in associate degree nursing programs. The director of nursing often must be the nursing clinical expert for the nursing home as well as possess administrative knowledge and skills.

Studies have shown the relationship between administrator and director of nursing education credentials and quality measures in nursing homes. For example, Trinkoff et al. (2015) found that higher education and certification for nursing home administrators (master’s degrees or higher) and directors of nursing (bachelor’s degrees or higher) resulted in better outcomes for selected quality measures. Castle et al. (2015) also found that nursing home administrators with more advanced educational backgrounds were associated with better quality of care in the homes. For these reasons, the Committee recommended that individuals holding any of these three positions have a minimum of a bachelor’s degree in their field, with preference that the director of nursing and social worker have a master’s degree.

Without regulations specifying basic degree requirements for directors of nursing, nursing home administrators, and social workers, most nursing homes will not recognize and act on the importance of a bachelor’s or graduate degree as a contributor to achieving quality care outcomes. Although there is research on the influence of administrator, director of nursing, and social worker education on quality of care in nursing homes (as highlighted above), it is limited. Therefore, a first important step to address the Committee’s recommendation is for the Center for Medicare and Medicaid Services (CMS) to require the collection of professional education degree and certification information using the Payroll Based Journal data collection process and create a quality indicator on whether a facility meets or exceeds the minimum education requirements for the administrator, director of nursing, and social worker. The availability of this information would assure consumers and policy makers that the nursing home is managed by appropriately educated personnel for their associated roles and responsibilities and for researchers to conduct more extensive studies examining whether the academic degrees and professional certifications held by these key personnel demonstrate a relationship to quality care. However, other factors need to be considered in such studies, such as tenure in the facility and length of experience in the role. Such research would provide evidence-based direction for nursing home regulations regarding qualifications for directors of nursing, administrators, and social workers.

National Competencies

The Committee recommended the establishment of national competency requirements for all licensed and unlicensed nursing home staff, including the medical director. It noted that a high priority on standards for competencies can improve quality and positively affect the recruitment and retention of nursing home staff and leaders. The Committee did not explicitly identify the full scope of competencies for various types of nursing home staff, but it strongly identified some that should be included, such as training in geriatrics and principles of diversity, equity, and inclusion. In 2008, the Institute of Medicine’s report Retooling for an Aging America: Building the Healthcare Workforce recommended that “all licensure, certification and maintenance of certification for health care professionals should include demonstration of competence in care of older adults as criterion” (Institute of Medicine, 2008, p. 161). This recommendation would require that national competencies for the nursing home workforce be identified such that demonstration of competence can be enforced through licensure, certification, and recertification, as well as through nurse aid training.

The development and implementation of national competencies for personnel working in nursing homes is a priority. These competencies should, at a minimum, focus on the following areas: (1) person-centered care and resident rights; (2) care of older adults, including assessment, care planning, and evidence-based geriatric care; (3) psychosocial care, including care of persons with dementia or mental illness; (4) infection prevention and control; (5) emergency preparedness; (6) palliative and end-of-life care; (7) diversity, equity, and inclusion; and (8) resident abuse prevention. The CMS should establish a panel of experts to develop competencies required for the various roles of personnel working in nursing homes and maintain a panel of experts to regularly review the national competencies and ensure they are current and meet evolving needs in nursing home care.

The majority of health professional education programs for licensed nursing home staff lack geriatric-focused didactic and experiential learning (Schapmire et al., 2018). Consequently, health professionals such as nurses, physicians, and social workers bring limited geriatric-focused knowledge to the care and services they provide to older persons residing in nursing homes (Rowe, 2021). For licensed professionals, required professional certification programs specific to the specialization of their role in nursing homes are needed to enhance their education and training. For example, the Committee recommended that the medical director complete education or certification specific to the care of older adults and certification in infection control and prevention. The American Board of Post-Acute and Long-term Care Medicine offers a rigorous certification program for medical directors, but only California requires this certification for medical directors (Steinberg, 2021). Several organizations (e.g. American Nurses Association, American Association of Post-Acute Care Nursing, American Organization of Leaders in Nursing) outline competencies for directors of nursing that are most often taught and achieved through graduate nursing programs (Joseph and Huber, 2015). These organizations also have certification programs that focus on these competencies. For licensed professionals, the national competencies could be built into professional certification programs.

The national competencies need to be built into nursing assistant training programs, which will likely affect the duration of the training programs. The Committee recommended an increase in the federal minimum training hours to become a certified nursing assistant from 75 to 120 hours. The increase in hours should be guided by the national competencies developed for nursing assistants and the amount of time necessary to acquire competence through both didactic and experiential training.

Currently, there is no required training for unlicensed direct care workers who do not complete basic training, such as dietary aides or recreation therapy aides (Washington State Department of Social and Health Services, 2016). Nursing homes have the option of hiring staff to assist with rehabilitation therapy who have not completed education programs meeting the requirements for occupational or physical therapy assistants. The CMS should require that all unlicensed direct care staff in nursing homes receive basic training in working with older adults. Even those individuals providing nondirect care, such as housekeepers and maintenance workers, should have basic training on infection control, communicating with persons living with dementia, and safety vigilance.

Importantly, training programs and nursing homes should retain in-person training as it remains the best practice and industry standard for direct care occupations (Trinkoff et al., 2017). Blended or hybrid training models can also be utilized as they augment in-person instruction and hands-on learning opportunities with classroom-based technologies. These modes of training delivery are preferable to fully online learning methods for certified nursing assistant training programs (Ochylski et al., 2017). Other modes of training delivery can include group demonstrations, paired work, call-and-response, role play activities, hands-on learning activities, job previews, and field practice (Trinkoff et al., 2017). The federal government (CMS), as recommended by the Committee, should reimburse entry-level training costs so that nursing homes can provide training to nursing assistants free of charge. States will need funding to strengthen direct care workforce training infrastructures and enforce the training standards (Paraprofessional Healthcare Institute [PHI], 2021).

The Paraprofessional Healthcare Institute (PHI) highlighted the need for better data on the unlicensed direct care workforce, including its credentials, and called out the inadequate and under-resourced federal and state data collection systems. The PHI urged the collection of direct care workforce statewide data and centralization of the training and certification records of direct care workers, noting the data collection infrastructure should be informed by a national minimum dataset for the direct care workforce (PHI, 2021).

The CMS should also develop requirements for ongoing demonstration of competency for persons employed in nursing homes per the Committee recommendations. National certification programs have criteria for recertification. A similar approach could be taken by the CMS. There may be some topics where annual review and demonstration of a competency is a best practice, such as infection control practices. Of utmost importance is ensuring training programs are designed to meet the unique demographic, cultural, linguistic, learning, transportation, and care needs of a particular population that includes residents, staff, and families. To this end, the Committee recommended ongoing diversity and inclusion training for all nursing home workers.

Preparing the Nursing Home Workforce

The Committee acknowledged that there is a deficit in health professional education programs to prepare health care professionals in competent, evidence-based care of older adults, particularly those in nursing homes (Oliver et al., 2011). The Committee recommended that all health professional education programs include “content related to gerontology, geriatric assessment, long-term care, and palliative care with additional preference for clinical experiences in nursing homes” (National Academies of Sciences, Engineering, and Medicine, 2022, p. 515).

The role of the registered nurse (RN) in nursing homes is particularly crucial to the quality of care provided to residents. The RN is ultimately accountable for the nursing care needed by residents 24 hours a day and 7 days a week and should conduct ongoing assessment of residents to detect, prevent, and mitigate negative outcomes such as falls, delirium, pressure injuries, and infections (Oldland et al., 2020). Thus, it is imperative that academic nursing programs substantially integrate geriatric nursing didactic and experiential learning in nursing curricula and expose all nursing students to nursing home settings through experiential learning. The American Association of Colleges of Nursing (AACN) and the Hartford Institute for Geriatric Nursing have developed baccalaureate competencies for nursing care of older adults (American Association of Colleges of Nursing [AACN], 2010). These competencies were developed to support the AACN Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008).Recently, the AACN completely revised the baccalaureate competencies around a framework that includes 10 domains and a large number of competencies and subcompetencies for both entry-level and advanced-level nursing programs (AACN, 2021). Gerontological nursing organizations should immediately conduct a comprehensive analysis of the AACN competency-based framework for professional nursing education and recommend how the proposed domains, competencies, and subcompetencies can be applied to the integration of gerontological nursing in nursing curricula. For example, the AACN notes that all entry-level professional nurses need knowledge and proficiencies to practice across a variety of settings, the lifespan, and diverse populations. Nursing students will be required to demonstrate the set of competencies in “hospice/palliative/supportive care which includes end-of-life care as well as palliative and supportive care for individuals requiring extended care or those with complex, chronic disease states or those requiring rehabilitative care” (AACN, 2021, p. 69).

The National Hartford Gerontological Center for Nursing Excellence (NHGCNE) has developed core competencies for gerontological nurse educators (Wyman et al., 2019). The NHGCNE has also developed the Distinguished Educator in Gerontological Nursing program (National Hartford Gerontological Center for Nursing Excellence, 2022). Both initiatives should be integrated into accreditation criteria for undergraduate and graduate nursing programs to ensure all schools have competent faculty in teaching nursing care of older adults. Other key health care professionals that must have strong competencies in caring for nursing home residents are physicians, including the medical director, and advanced practice providers (e.g. nurse practitioners, physician assistants). Many would argue that these providers should be trained as specialists in geriatrics; however, the current number of gerontological nurse practitioners and geriatricians is inadequate to provide care to residents in the nation’s approximately 15,600 nursing homes. As such, recruitment of those who will work in these fields is equally as important as their preparation.

The Institute of Medicine report on retooling the health care workforce to meet the needs of an aging population recommended providing financial incentives to increase the number of geriatric specialists in all health professions and to include specific enhancement of reimbursement for clinical services delivered to older adults by practitioners with a certification of special expertise in geriatrics (Institute of Medicine, 2008). Incentives might include relieving financial burden by providing direct financial support for the education of those committed to jobs in nursing homes, providing loan forgiveness for those who commit to work in nursing homes located in underserved areas (e.g. rural, disadvantaged neighborhoods), providing retention bonuses to full-time workers who remain in their positions for 1 year, and providing cost of living adjustments to help with attaining a livable wage. These recommendations should be seriously considered by the CMS and state entities that provide Medicaid reimbursement to nursing homes to ensure that residents in nursing homes are receiving the highest quality medical and clinical care.

Changing perceptions of working in the nursing home environment is additionally imperative (Koh, 2012). In health care professional education programs, there is a dearth of faculty with experience in nursing homes and, subsequently, familiar with the nursing home environment (Mueller et al., 2011). Faculty enthusiasm for professional practice in nursing homes (accompanied by knowledge in geriatrics/gerontology) can positively influence students’ perceptions about learning in a nursing home setting and potentially their desire to be employed in such a setting. A priority is to increase the number of experienced and enthusiastic faculty in health professional programs to teach courses and lead practicum experiences and to ensure nursing home practicum placements are as essential as, and equal in importance to, experience in acute care settings (Cooke et al., 2021). Incentives to garner faculty interest in this area are needed. Academic institutions and foundations can create funded faculty fellowships focusing on teaching in nursing home settings. Academic programs can recruit professional nursing staff already employed in nursing homes to graduate education programs that would enable them to subsequently serve as faculty. Federal agencies such as the Health Services Resource Administration could establish programs to support the development of faculty to teach and lead practicum experiences in nursing homes.

Once programs that facilitate experiences in nursing home for trainees are established, it is critical that these programs are meaningful and effective. For example, nursing homes should work with academic institutions to develop thorough orientation processes specific to the nursing home, which might include placement learning objectives, preregistration modules that review caring for older people in nursing homes, and preexposure to nursing home staff (Mueller et al., 2011; Young et al., 2021). Trainees should also be made to feel welcome in the nursing home setting, thereby creating a culture among nursing home staff that reflects an inviting environment.

With regards to creating a pipeline for the nursing home workforce, one viable strategy is targeting high school students for health professional programs. High school students could complete training as nursing assistants while earning their high school diploma to move directly into employed nursing home positions after graduation (Alvarado, 2014). Continuing their trajectory to licensed health professional roles that can be continued in the nursing home setting is a strategy to build a workforce for nursing homes.

Conclusion

Significant and urgent action is needed by governmental and professional organizations to ensure residents in nursing homes are provided high quality care and services by a competent workforce. This article provides specific federal, state, and organizational policy recommendations with a focus on education, training, and overall preparation of the nursing home workforce to achieve that goal (Table 1). It is now the responsibility of the relevant bodies referenced (and not referenced) herein to commit to moving these recommendations into action.

Significant and urgent action is needed by governmental and professional organizations to ensure residents in nursing homes are provided high quality care and services by a competent workforce.

Acknowledgements

This supplement is sponsored by The John A. Hartford Foundation.

Contributor Information

Christine Mueller, University of Minnesota School of Nursing, Minneapolis, Minnesota, USA.

Jasmine L Travers, New York University Rory Meyers College of Nursing, New York, New York, USA.

Funding

None.

Conflict of Interest

J. Travers served as the contact editor for the supplement, in which this article is included, but was not involved in the review or decision for the article.

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