Nursing Home Staffing Instability During and After the Acute Phase of the COVID-19 Pandemic

Nursing homes are essential in providing care to millions of Americans, with staffing being a crucial factor in providing high quality care. Adequate staffing levels, typically measured as hours per resident day (HPRD) and often measured separately for registered nurses (RNs) and for certified nursing assistants (CNAs), are vital for nursing home quality. Prior studies have shown that staffing instability is associated with poor health outcomes and adds to poor outcomes above and beyond low average staffing and turnover. The importance of staffing is widely recognized and is increasingly becoming a policy focus.

Despite its importance, maintaining adequate staffing has long been a challenge for nursing homes, and this was recently exacerbated due to the COVID-19 pandemic. During the COVID-19 pandemic, nursing homes faced a notable decline in total nurse staffing hours, especially for CNAs. This decrease in staffing levels was particularly pronounced from April to December 2020, with monthly decreases of 5% to 11% in total nurse staffing hours and 6% to 13% in CNA hours compared to the previous year. While staffing as measured as HPRD actually increased slightly during this period due to decreases in resident population, these small increases were achieved only with great difficulty and increased reliance on contract staffing. Moreover, staff faced additional responsibilities due to caring for residents during the pandemic, necessitating more staff time. Additionally, specific types of nursing homes, such as those with a higher proportion of racial and ethnic minority residents, had even more difficulty maintaining adequate staffing than others.

While it is known that the COVID-19 pandemic resulted in nursing homes having difficulty maintaining adequate staffing, it is not known how staffing stability was impacted by the pandemic. The purpose of this study is to examine changes in stability of nursing home staffing during the COVID-19 and to determine if specific nursing home characteristics were associated with greater adverse changes in staffing stability.


Key Questions

This project aims to answer these questions:

  • Did nursing home staffing stability get worse during the COVID-19 pandemic and, if so, has it returned to pre-pandemic levels and when did it return?
  • Was staffing stability during the pandemic more impacted in some types of nursing homes than others? For example, were nursing homes with higher proportions of racial and ethnic minorities more impacted? Other characteristics of interest include proportions of residents with Medicaid as their primary payer, rural location, profit and chain status, and star rating.


This study is a collaboration with RTI International.

For more information, contact Joanne Spetz.