Staffing shortages and turnover rates have recently become a pertinent topic for hospitals. However, these personnel challenges have haunted certified nursing facilities since the 1970s. Even before the COVID-19 pandemic, the turnover rate for total nursing staff in nursing homes was about 128 percent. While increasing transparency on these atrociously high turnover rates has been a commonly proposed solution, it has only recently been enacted. The Centers of Medicare and Medicaid Services (CMS) announced in January 2022 that weekend staffing levels and annual staff turnover rates will now be publicly accessible through the Care Compare website. But, can transparency fix staffing problems in nursing homes?
Prior to understanding the role that transparency may play in staffing challenges, it is critical to understand the specific role that staff plays in long-term care. Unlike other health care settings, long-term care patients require daily, longitudinal care for weeks, months, and even years. While physicians are an important part of the care team, a disproportionate percentage of the resident interactions are with the nurse aides and nurses. Due to the limited abilities of many of the residents, these staff members often bathe, dress, and feed residents. It is impossible to respectfully perform these responsibilities without developing trust between the residents and the staff. Therefore, it is not possible for their interactions to be transactional. Each interaction is meaningful.
However, high staff turnover rates threaten the sanctity of the interactions and attempt to convert the interactions into emotionless tasks. This change not only breaks the trust of the residents but also drains meaning from the job for the staff member, which further exacerbates the staff turnover cycle.
The COVID-19 pandemic has heightened strain on long-term care staff. Since many visitors have been restricted from seeing their loved ones in long-term care due to infection control measures, staff members have had to take on full responsibility for cognitive and emotional engagement. By adding these additional obligations to their pre-existing health and safety responsibilities, the work has become both more physically and emotionally taxing for staff members and more necessary for residents.
When a family attempts to find a suitable long-term care community for their elderly loved one, information on the long-term care community is critical. The goal of transparency in long-term care is to help families confidently place their loved ones in a new home during one of the most vulnerable times of their lives. Therefore, it is logical to believe that increased staffing transparency would help families. However, transparency only enhances decision-making by making it possible to compare feasible options. Since most long-term care communities in the same geographical area have similar turnover rates, families do not have many alternative options. Therefore, it is possible that increased transparency in this situation does not lead to any changes, let alone improvements, in decision-making.
In situations where there are substantial differences in staff turnover rates between certified nursing facilities in the same area, increased transparency aims to show the administration the financial need to address staffing shortages. Specifically, we hope that families visit the Medicare.gov Care Compare website, identify turnover rate metrics, understand the quality-of-life implications of these rates, choose against placing a loved one in a nursing home with high turnover rates, administration at these communities notice a decrease in interest, administration ascribes the decreased interest to the high turnover rate, and finally, administration commits more resources to better the staffing challenges. The likelihood of this cascade of events panning out as planned is impractical.
While transparency in medicine has improved decision-making around drug prices and costs of procedures, transparency for staffing turnover rate in nursing homes likely will not address the staffing challenges. Instead, it may make matters worse. Rather than reassuring families that their decision is an educated one, it shows them that they may have no good options.
Harsh Moolani is a medical student.
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