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Health care will hemorrhage staff unless changes are made, advocates say

A detached, low-rise office building. A sign out front reads "SKILLED NURSING AND REHABILITATION"
Darlene Johnson
Photo of a hiring sign in front of Richmond's Lakeside Health & Rehabilitation Center, a nursing home. The facility recently transferred from ProMedica Senior Care, whose logo is still visible.

Lawmakers introduced proposals this General Assembly session to help improve standards at Virginia nursing homes and facilities — and to address the health care worker shortage exacerbated by the COVID-19 pandemic.

Del. Bobby Orrock Sr. (R–Caroline) introduced House Bill 1446, which would set minimum staffing requirements for certified nursing facilities. A nursing facility (which includes nursing homes) provides health-related services on a continuing basis, according to state code.

The measure passed the House on a vote of 95-2 and was sent to a Senate finance committee after unanimously clearing a Senate health committee.

“At the end of the day, I do think it’s going to be a step forward in the quality of patient care,” Orrock said.

Del. Vivian Watts (D–Fairfax) also introduced a bill, HB 1564, that would have established regulations for minimum staffing in nursing homes — as well as care standards. The bill was never heard in committee and is dead for the session.

A decreased supply and an increased demand for nursing staff have added to the largest nursing staff shortage U.S. history, according to a Nurse Journal article. The COVID-19 pandemic widened the supply-demand gap, and the shortage is expected to worsen in 2023.

Eighty-six percent of nursing home and assisted living facility staff surveyed by the Virginia Heath Care Association and Virginia Center for Assisted Living reported an “overall worse workforce situation” in 2022 compared to 2020. The results are 5 percentage points higher than responses given to the same question in 2021.

VHCA-VCAL is Virginia’s largest association advocating for long-term care providers. Only 3% of survey respondents reported a full staff, and 16% reported a “crisis” with numerous shift vacancies but not enough qualified applicants. Many critical roles are unfulfilled due to vacancies, according to the organization.

The national average of daily staff hours per resident is 3 hours and 45 minutes, and the state average is 3 hours and 35 minutes, according to Medicare. Longer staff hours per resident per day are better, according to Medicare.

Watt’s bill would have established the minimum amount of hours of care per resident at 3.5 hours by 2027 and then increased incrementally, up to 4.1 hours by 2033.

“You really can’t give quality care when you’re short [staffed],” said Denise Davis, who has worked in health care for 20 years. She currently works as an agency nurse contracted at Lakeside Health & Rehabilitation Center, a nursing home in Richmond: “It’s just the bare minimum.”

The total number of daily staff hours per resident at the center where Davis works is just under 3 hours, according to Medicare. The center has an average of 166 residents per day, according to the same Medicare profile. The national average of nursing home residents per day is almost 79; the statewide average is 92 nursing home residents per day.

The top three reasons for overall staff loss since the COVID-19 pandemic began are burnout, contract or travel work, and leaving the health care industry altogether, according to VHCA-VCAL.

Davis often works double shifts and gets called in to cover regular staff shifts, she said. Almost every facility that responded to the VHCA-VCAL survey needs staff to work overtime or take extra shifts. Facilities still rely heavily on outside staffing, according to VHCA-VCAL.

Despite active recruitment, 93% of facilities have vacancies for certified nurse aids, and 87% have vacancies for higher paid licensed practical nurses, according to VHCA-VCAL.

Long-term care providers are not paid well and there is competition for similar or higher-paying opportunities, stated Del. Dawn Adams (D–Richmond) in an email. Adams is a nurse practitioner and co-patron on Orrock’s bill.

“Finding individuals to provide care in an arena that is often physically and emotionally demanding remains a challenge,” Adams wrote.

There are different types and tiers of staff at nursing facilities. This includes agency nurses that do contract work at different nursing facilities. Travel nurses have similar contracts and travel to different facilities for work. There are also training nurse aids, who assist nurses and CNAs but are not certified or licensed.

Asia Jones, a TNA at Lakeside Health & Rehabilitation Center, said she has a greater workload due to staff shortages. Jones’s duties as a TNA include getting vital signs, and feeding and changing the patients.

“We’re not really supposed to be actually physically touching the patients … or taking on whole floors [of patients] by ourselves,” said Jones about her experience.

She does not feel adequately trained to work towards becoming certified: "They kind of threw me on the floor the first day and just told me to shadow the other CNAs."

Both House bills proposed minimum standards for the qualification and training of nursing staff in nursing homes, hospitals and certified nursing facilities with the exception of staff licensed or certified by the Department of Health Professions.

Watts proposed minimum standards in nursing facilities starting 20 years ago, she said — but lack of advocacy and cost are reasons the bills have not passed.

“I look at these people in our nursing homes and they’re not just aging people … to be just ignored, to be thrown away,” Watts said.

The strain on health care staff due to the COVID-19 pandemic shined a “harsh spotlight” on nursing home conditions, Watts said. Lack of staffing also makes it hard to enforce minimum standards.

It is unsafe for patients to have an inadequate staff-to-patient ratio and it overburdens staff with patients, said nurse practitioner Ashley Apple. She's the commissioner on government relations for the Virginia Nurses Association and an assistant professor of nursing at the University of Virginia.

The VNA is an advocacy group that represents over 100,000 nurses and works to advance professional practice and encourage the delivery of quality care, according to its website. The organization’s advocacy work focuses more on hospital settings than nursing homes.

The health care industry will continue to “hemorrhage health care workers” if legislators don’t realize workplace protections are needed for employees and patient safety, Apple said. According to her, health care workers are saddled with more work than they can manage.

“There aren't enough minutes in the day to provide the level of care they want to provide,” Apple said. “It's morally distressing to health care workers.”

Capital News Service is a program of Virginia Commonwealth University’s Robertson School of Media and Culture. Students in the program provide state government coverage for a variety of media outlets in Virginia.

Capital News Service is a program of Virginia Commonwealth University's Robertson School of Media and Culture.