Workforce Issues in Long-Term Care: Is There Hope for a Better Way Forward?

Workforce challenges are a persistent feature of the long-term care landscape, while the landscape itself is shifting. In the United States, from 1985 to 2015, a decline in the proportion of low-acuity residents has occurred in concert with the growth of assisted living (Silver et al., 2018) and a shift of Medicaid-financed long-term care toward home- and community-based services (Eiken, 2015). As a result, nursing homes serve a larger proportion of people who are admitted from hospitals and paid for by Medicare (Fashaw et al., 2019). As acuity of care needs increases in these settings, the industry increasingly depends on a complex myriad of direct care and specialized workers. Workforce issues intersect with provider and policy interests: The workforce is the providers’ largest cost, whereas policymakers see the workforce as a lever to influence the quality of care. Workforce issues also intersect with larger social issues. For example, immigration policy influences the long-term care workforce, as do state and federal minimum wage laws. The larger economic environment and prevailing wages in other service industries affect the labor supply, especially in long-term care. As we saw in 2020, existing workforce concerns collided with infection control and acute illness care during the pandemic of coronavirus disease 2019 (COVID-19). Lastly, but not least in importance, workforce issues affect the quality of life for the people who live in long-term care settings. In short, workforce issues are the most significant challenges facing the long-term care industry.

Although considerable research attention has been paid to long-term care workforce topics, the editorial team at The Gerontologist recognized that important questions remain, prompting the call, in the fall of 2019, for this special issue on workforce issues in long-term care. We little knew when the call for papers went out that a pandemic would throw a bright spotlight on long-term care, especially nursing homes, making this issue even more timely. The articles in this issue paint a picture of stagnated progress and thorny challenges, but their rich and varied methodologies and perspectives also offer the field some glimpses of optimism that we can leverage diverse approaches to improve long-term care.

Taking a broad perspective, Foley and Luz (2021) evaluate progress on the workforce development goals set forth in the 2008 Institute on Medicine (IoM) report “Retooling for an Aging America” (IoM, 2008). They highlight the continuing shortages of both geriatricians, a workforce sector that appears to be shrinking despite the increasing need, and direct care workers. Their conclusions are disturbing: Since 2008 only one of the IoM report recommendations has been completely met, and several have not been addressed at all. As the numbers of older patients grow, the United States, at least, has made little progress on meeting the workforce pressures to meet their care needs.

Scales’ (2021) Forum article summarizes the current state of the direct care workforce, highlighting the preponderance of women of color and emphasizing how the work of caring continues to be devalued, as manifested in poor compensation, heavy workloads, and inadequate training and support. Despite these ongoing challenges, Scales offers optimism and a call to action, noting the opportunity to leverage the emergency responses to the COVID-19 pandemic and the crisis in long-term care settings it engendered. She calls for disseminating tested interventions, especially upskilling and empowering direct care workers and changing to value-based payment models. Two studies in our collection support these recommendations. Wu et al. (2021) studied the impact of a policy change in Taiwan that instituted a new payment system for home care services. The policy shifted payment from a per-hour rate to a per-service rate, increasing flexibility of home care workers’ time and allowing the opportunity for higher reimbursement for more efficient service delivery, leading to an increase in the workforce. Gleason and Miller (2021) found that supervisor support and degree of control on the job were associated with home health aides’ job satisfaction and intention to leave among respondents to the 2017 Massachusetts Home Care Aide Survey. Together these two studies illustrate how policy and workplace practices might influence workforce size by attracting workers, on the one hand, and retaining them, on the other.

Articles by Castle (2021) and Kennedy et al. (2021) are also relevant to the important challenge of retaining direct care workers. Castle points out that the problem cannot be studied adequately if the concept of retention is not operationalized adequately. In this useful measurement study, he compared different definitions of retention, integrating data from the Nursing Home Compare and Certification and Survey Provider Enhanced Reporting databases. He concludes that the best indicators of care quality are 3- and 5-year retention rates. Kennedy et al. compared retention rates for direct care workers in assisted living and nursing homes using an Ohio data set. Their results showed comparable retention rates across settings, but predictors of retention differed. Retention strategies should take into account context, including work settings and their attendant resources and regulation.

Although long-term care workforce policy is often associated with standardized quality indicators, these are only indirectly associated with resident quality of life. Using a novel, hermeneutic approach to policy analysis, Hande et al. (2021) examined the connections between decentralized Canadian long-term care regulations and resident quality of life. They found that newer regulations tended to provide more flexibility for staff to promote resident quality of life. Despite the overall tendency of regulations to be rigid and safety-oriented, the findings offer some optimism that more flexible regulations might support the goal of empowering staff to emphasize quality of life for residents.

Whereas the aforementioned articles approached the direct care workforce from a policy and large data set perspective, three qualitative papers privilege the perspectives of those workers. Douglas et al. (2021) explored the pressures associated with mealtime assistance, a burdensome task that is often an “extra” duty for nursing assistants. Their findings show the importance of training for this task, emphasizing the importance of verbal and nonverbal communication skills to this intimate social interaction. Cooke and Baumbusch (2021) further examined the interpersonal climate of the care facility in their critical ethnographic study of two Canadian nursing homes. This work documents power dynamics among nursing home staff, showing how incivility and bullying relate to team collaboration, and how these dynamics affect care delivery. Cooke and Baumbusch conclude that, although increasing staffing numbers may alleviate some care burdens and improve quality of care, considering who is working and how they interact may be equally important. Themes of managing time pressures cut across these qualitative analyses and are the focus of a study of Swedish nursing assistants (Lundin et al., 2021). The workers’ accounts depict nursing assistants as a collective “we,” facing, on the one hand, the “they” of residents, largely drawn as passive recipients of care, and, on the other hand, the “they” of administrators who impose burdens that are not always related to direct care of residents. This paper explored how workers prioritize their time among these demands, the values that they use for prioritizing, and how those values are compromised. Together these three qualitative studies enrich our understanding of the day-to-day experiences of direct care workers and emphasize how institutional contexts may affect the link between workers and quality of care.

The challenges faced by direct care workers are compounded by an external environment that devalues this work. The systematic review by Machha et al. (2021) found that work in aging care remains highly stigmatized. This review applied a linguistic framework to English-language articles addressing stigma in aging care. The analysis demonstrates how the work of caring for older people and the workers who do this work are stigmatized, although the nature of that stigmatization depends on the social position of the people studied. Unsurprisingly, such stigma affects recruitment, job satisfaction, and worker well-being.

The joint import of support and training connects the quantitative and qualitative work in this collection; enhancing the direct care workforce involves increasing numbers and increasing their skills. A key skill needed in all long-term care settings is the ability to work with people living with dementia. McKay et al. (2021) address training directly in their comparison of a traditional skills training approach to an approach based on an occupational adaptation (OA) framework. Although both groups improved in skills mastery, the OA-based group showed greater gains, developing more cooperative approaches to solving the complex problems typical in dementia care. This exploratory study suggests that OA-based training has the potential to address climate and skills issues that challenge worker satisfaction and effectiveness in long-term care settings.

As Foley and Luz (2021) point out, the increasing acuity of nursing home residents demands changing models of medical care delivery. Katz et al. (2021) review current models, noting that shortages of geriatricians have led to greater proportions of care delivered by nurse practitioners, physician assistants, and skilled nursing facility specialists. At the patient care level, involvement of these nonphysician professionals may lead to higher quality of care, but Katz et al. argue that there is insufficient research to determine which models of care are ideal. They call for rigorously testing these models in the future. As a start, Wagner et al. (2021) regressed Nursing Home Compare quality measures onto provider and institutional characteristics. They found that having a staff physician was associated with fewer emergency room admissions, but greater use of antipsychotic medication for long-stay residents. Their findings suggest that policies that favor a particular model may not yield unambiguously positive outcomes. Further research is needed to compare different care models directly to one another. McGilton et al. (2021) demonstrated how, during the COVID-19 crisis, nurse practitioners in rural and urban Canadian nursing homes took on the burdens of containing the spread of the virus, stepping in to cover gaps across the workforce spectrum from nursing to medical care, providing support for staff and families, and creating linkages across health care systems such as emergency medicine and psychiatry. Nurse practitioners in this qualitative study demonstrated flexibility in being able to span the complex needs of postacute care systems, supporting McGilton et al.’s call for increasing the formal involvement of nurse practitioners in these systems.

Clearly, administrative structures, workplace climate, training, and support are important factors in creating a thriving workforce for long-term care. Missing thus far in the articles discussed is a focus on the individuals with the most administrative power within these settings: administrators and directors of nursing. A scoping review by Siegel and Young (2021) reveals important gaps in our knowledge about these key players. They found no studies of how administrators and directors of nursing work together to navigate the complexity of demands they face, although anecdotal evidence suggests that this relationship is critical. This review suggests that there is a great need for theory-based studies of the organizational process to understand how to improve important workplace characteristics to make long-term care jobs more appealing.

Overall, this collection of articles spans the long-term care workforce from the front line to the back office, from rigid hierarchies to flexible models that promote creativity. When we started on the path to producing this collection, we knew that the way forward would have to negotiate a complex and changing landscape. If the shared goal is that long-term care should provide both high-quality care and the opportunity for a good life, the resulting articles lay out many of the challenges faced by policymakers, practitioners, and providers. At the same time, new models of care and new ways of thinking about and defining “work” have perhaps moved us a few steps down the path. The COVID-19 pandemic has laid bare the need to reinvest in the long-term care workforce, and we hope that this collection will provide positive guidance for future research and policy.