Q&A: Nursing homes hardest hit by health care employment declines

Among health care job sectors, nursing homes have been the most adversely affected by declines in employment growth since the pandemic—a rate more than triple that of hospitals or physician offices, says a University of Michigan researcher.

Employment at nursing homes is 10.5% below pre-pandemic levels compared to 3.3% for hospitals and 1.6% for physician offices, according to a study by Thuy Nguyen, assistant professor of health management and policy at U-M's School of Public Health, and colleagues.

The study, published Nov. 2 in JAMA, evaluated pre- and post-pandemic health care employment levels to identify subsectors hardest hit by job losses and recovery.

The shortage of nursing home workers—and health care workers in general—isn't new, but the study can help inform policy change, including a federal proposal targeting staffing levels at skilled nursing facilities, or SNFs, said Nguyen, who is lead author of the study.

"The Biden administration's proposed nursing home staffing standards aim to boost staffing in nursing homes by setting national mandatory minimum nurse staffing levels, which has the potential to positively impact declining SNF employment levels and eventually to improve quality outcomes for nursing home residents," Nguyen said.

"The findings of our research can help to define the scale of the challenge faced by policymakers. These declines in SNF employment levels are likely multifaceted in nature, and the Biden administration's proposal alone is unlikely to fully address the myriad of reasons for declining employment in this health care subsector."

Nguyen and co-authors Christopher Whaley of Brown University, Kosali Simon of Indiana University and Jonathan Cantor of RAND Corp. used U.S. Census Bureau national labor statistics to assess employment recovery since an initial decrease in employment after the March 2020 public health emergency through the end of 2022.

"These data come from a census of employment and wages that covers 95% of jobs in the U.S. As the post-pandemic recovery continues, these same government databases will be important to watch for future changes in health care sector employment," Simon said.

The study fills a void in research by offering more recent data than typically available to evaluate the broad health care workforce, says Nguyen, who addresses the worker shortage below.

What is your opinion on the direction of the staffing shortage? Will it get worse before it gets better?

Understanding the causes and consequences of diverging recovery patterns of health care employment is beyond the scope of our study, but our findings underscore the potential for further declines in employment in certain areas such as long-term care workers. These results are concerning as they suggest long-term consequences of the COVID-19 pandemic on declining health care employment such as long-term care workers' decisions to leave the industry. I think without more targeted efforts from policy makers and health care organization leaders we may not see the brighter picture on long-term care employment in the near future.

Any surprise findings?

It was surprising that health care employment declined less rapidly than non–health care employment in 2020 but recovered less quickly in 2022. Employment recovery patterns varied greatly by health care subsectors. For example, staffing in SNFs had already declined pre-pandemic and further declined after the pandemic—12% below the pre-pandemic level by the end of 2022, while staffing in offices of physicians reached pre-pandemic levels.

What kinds of policy changes are needed or are already happening?

Addressing the long-term care employment shortage is a pressing public health issue in the U.S. Among the ongoing policy changes, the Biden administration's new proposal on setting national mandatory minimum nurse staffing levels may improve the situation to some extent.

However, this proposal alone is unlikely to fully address declining employment among long-term care employees as many of these employees have faced various struggles such as burnout, a lack of available child care and modest wage levels. Leaders of health care organizations should consider increasing wages and improving working conditions for long-term care workers to address the short-term employment shortage while also focusing on long-term retention. The government should provide further financial support and make it easier for individuals to enter careers in nursing homes or other heath care sectors.

How concerned should patients, health care workers be about the staffing shortage?

The current staffing shortage at nursing homes is likely to continue to exacerbate staff burnout and high turnover. Higher levels of nurse staffing and a higher skill mix appear to be associated with better quality outcomes for nursing home residents. This raises concerns for quality of care at nursing homes among patients, health care workers, as well as health care organizations' leaders.