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The pandemic pummeled long-term care – it may not recover quickly, experts warn

Nurse's aide Patricia Johnson has worked for the Ambassador Nursing and Rehabilitation Center on the north side of Chicago for nearly 24 years. The pandemic has been grueling on her and her colleagues. "The hardest part is watching people die alone without their families," says Johnson, who now sometimes works double shifts due to staff shortages.
Jennifer Swanson/NPR
Nurse's aide Patricia Johnson has worked for the Ambassador Nursing and Rehabilitation Center on the north side of Chicago for nearly 24 years. The pandemic has been grueling on her and her colleagues. "The hardest part is watching people die alone without their families," says Johnson, who now sometimes works double shifts due to staff shortages.

Nursing homes and other long term care facilities have lost a record number of residents and staff to COVID-19 – representing abouta quarter of all COVID deaths in this country.

Now, the industry is suffering through a historic staffing shortage, further exacerbated by omicron. Workers have quit in record numbers since the pandemic started. And during the worst of omicron many frontline staff had to stay home because of breakthrough infections.

"Quite frankly, it's been pretty brutal here," says Nathan Schema, president and CEO of the Good Samaritan Society, a large non-profit provider of long-term care in the country, with facilities in 23 states. From Washington to Florida and from Maine to California, facilities and staff are struggling.

Of Good Samaritan's 15,000 staff, several hundred tested positive for COVID-19 during the worst part of the surge, Schema says, putting them into contingency staffing across the organization. "In some of our more rural communities, it doesn't take, but, one or two nurses to be out with COVID to really create a tough situation."

Absences and staffing shortages leave those still showing up for work carrying the burden.

"You can see it in people's eyes – the tiredness, the exhaustion," says Jenna Szymanski, a nurse at the Good Samaritan Society's Luther Manor in Sioux Falls, South Dakota. "All the staff, I think, are pretty burnt out right now."

Researchers are concerned the situation could have a lasting impact on an industry which has struggled with a high rate of turnover and staffing shortages for a long time.

"At some point, you know, the system is going to fracture because people need care," says Tricia Neuman, a senior vice president with the Kaiser Family Foundation. "And you can't get by without someone there to provide basic daily needs."

Frontline workers face exhaustion

Around the country, the entire industry is feeling the strain, with managers having to fill in for other staff who are out sick, Schema says. He's had to limit admissions and close a few facilities in two states.

So has Tabitha, a non-profit senior care provider in Nebraska, which had to close two short-term and one long-term care unit because of staff shortages, says Christie Hinrichs, CEO of Tabitha.

That, in turn, is causing backups in hospitals, she says, as they are unable to discharge patients who need long term care. "But we don't have the staff to care for them," she says.

But the pressures of the situation can often be worst for the low-paid staff that make up the backbone of daily care in the industry: nursing aides.

"The stress is unbearable," says Patricia Johnson, a nurse aide at Ambassador Nursing and Rehabilitation Center in Chicago.

Johnson's daily duties include everything from regularly checking in on residents, to feeding them, documenting their food and water intake, and helping them go outside for fresh air or a smoke.

The pandemic had already made her and her colleagues work much harder.

"You've got to basically keep yourself safe, keep the residents safe, and then you've got to make sure that you do everything that you're supposed to do," says Johnson, who has lost residents, colleagues and cousins to COVID-19.

The recent staff outages linked to omicron only made things worse. She's had to put in extra hours, do double shifts, and she hasn't taken a vacation since the start of the pandemic.

She hesitates about taking time off because it will only add to her colleagues' workload. "We're just trying to work and keep everything together, basically," says Johnson.

At the western edge of the country, in a long-term care facility in Bellingham, Wash., there have been times in recent weeks when nurse's aide Sherylon Hughes was the only frontline staffer who showed up to work when two or three were needed.

"There would be a lot of scrambling to try and get somebody to stay from the previous shifts to get someone else to come in," says Hughes. "I got to work with a lot of my managers that weren't expecting to work and stay up all night, but that's what we had to do."

She'd never seen her facility hire so many temporary workers.

"It's definitely like a last resort for a facility that is desperate," she says. "By the time they figure out how we do things and they get comfortable and get to know our residents, the contract is over and they leave. So it's sort of a continuous influx of people who are just learning the ropes."

Sherylon Hughes is a nurse's aide at North Cascades Health and Rehab Center in Bellingham, Wash. She's worked at the facility for over a decade and says that the recent staffing shortage is the worst she's ever seen.
/ Chona Kasinger for NPR
Chona Kasinger for NPR
Sherylon Hughes is a nurse's aide at a long-term care facility in Bellingham, Wash. She's worked at the facility for over a decade and says that the recent staffing shortage is the worst she's ever seen.

Lowered standards and moral distress

Hughes says there have been times when she's had to care for as many as 25 residents — it's affecting the level of care she can give.

"If there was a fall or something else bad happening, say there is a confused resident having a hard time that really needs one-on-one attention, and you're not able to give it to them to get them to calm down so that they can rest, that is frustrating. It's sad, and it makes you want to not go back to work," says Hughes, who has worked at the facility for more than a decade.

This is a common theme among frontline workers across the country.

In South Dakota before the pandemic, Szymanski says she could visit with each of her residents, "spend more time focusing on making sure they're OK, mind, body and soul."

These days, she's hardly able to have that kind of one-on-one time. And she's concerned she's missing the little things that can go a long way towards improving her residents' well-being, like washing or curling someone's hair.

"I feel I am not able to provide the care that I would like to provide," says Szymanski.

Frontline workers in long term-care are feeling they are letting their patients down, says Susan Reinhard, executive director of AARP's Public Policy Institute.

"If you have too many people to care for, you're going to feel moral distress like, 'I'm not doing my best. I can't do the best job I've been trained to do,'" says Reinhard. "That is really devastating personally, just day after day."

"That leads to more collapse, that leads to more people choosing not to work anymore," says Hughes.

A chronic problem exacerbated by the pandemic

A recent industry report estimated that nursing homes and assisted living facilities together have lost more than 250,000 jobs since the start of the pandemic. And an analysis by the Kaiser Family Foundation suggests the industry has continued to have problems employing people while other health service industries have recovered in the past year or so.

However, the industry's staffing issues didn't start with COVID.

"We know that even before the pandemic, two years ago, there were already staff shortages," says the AARP's Reinhard. "It's a perennial problem."

It's a hard job, with low pay, especially for those providing direct care, like nursing aides.

And it's physically and emotionally demanding, adds Hughes.

"You're lifting and pushing and pulling [people]," she says. "You have to have a strong stomach. We're dealing with people's bodily functions. You have to be able to stand that."

It can be sad to watch residents with dementia and other degenerative disorders decline over time. "That can be distressing," she says.

The work becomes even more demanding when there are fewer people doing it, says Laurie Brewer, the long-term care ombudsman for New Jersey. Many facilities, especially for-profit ones, have not been meeting minimum staffing requirements, she says.

"Sometimes money is not the problem," says Brewer. "It's working conditions that are the problem."

The pandemic only exacerbated all these issues, by making the work even harder, and bringing more personal risk to long-term care workers, says Neuman. They have put their own lives and those of their loved ones at risk. They have watched their colleagues and residents die of COVID-19 in record numbers.

"So it's just been a lot tougher now," she adds.

Hughes says there was a "significant mass exodus of nurses, nurse's aides, office workers, nurses" at her facility.

But COVID has inspired some improvements in many facilities, including pay raises

"For our certified nursing aides, we made about a 15% increase last fall," says Tabitha CEO Hinrichs. And she's planning another 5.5-6% raise for all nursing staff soon.

In Bellingham, Hughes' employer has given staff hazard pay, and last year, she and her fellow union members negotiated raises. She and her colleagues are lobbying for more state funding for the industry and to make sure the money goes directly to frontline staff.

"There just isn't any other way to fix this problem. We have to be able to offer a better living wage to people that are going to be coming in and doing one of the most important jobs in health care," she says.

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Rhitu Chatterjee is a health correspondent with NPR, with a focus on mental health. In addition to writing about the latest developments in psychology and psychiatry, she reports on the prevalence of different mental illnesses and new developments in treatments.