What Our Readers Had to Say About RN Staffing in Nursing Homes

By Maureen Shawn Kennedy, AJN editor-in-chief

nursing homeEarlier this month, AJN’s managing editor Amy Collins wrote a post about nursing homes, basing her discussion on a New York Times article by Paula Span at the paper’s New Old Age blog that examined efforts to address the inadequate number of registered nurses (RNs) in nursing homes. While federal regulations for agencies that receive Medicare or Medicaid require 24-hour nursing services, they only require an RN to be on site for eight hours daily. According to Span, 11.4% of nursing homes did not meet this requirement.

Collins found confirmation of this information in her own experiences visiting her grandmother in nursing homes:

“There always seems to be a lack of staff—and with so many residents these days suffering from varying levels of dementia and memory problems, staff are needed more than ever.”

We linked to the blog post on our Facebook page and received a tremendous number of comments on both sites. While both Span and Collins emphasized that increases in all levels of nursing personnel are needed, some LPNs responded to our post to assert that they too have valuable skills, as well as extensive experience, in this setting—and that a broader underlying problem is inadequate staffing tied to corporate cost-cutting.

Few people would argue with these assertions. Most LPNs do the best work they can despite impossible patient ratios. Most LPNs are assigned too many patients. Even so, there’s also a real need to increase the number of RNs in nursing homes. We know from research (and you can find links to some of the studies in Span’s article) that there are fewer adverse events when RNs are managing care. Many comments on Facebook and this blog drive the message home. Here’s a sampling:

“Having two large medication passes in one shift gives any nurse with 15 to 25 patients no opportunity to do what RNs do: assess, diagnose, plan, intervene, and evaluate. I don’t’ care how good you are…”

“Insurers are not recognizing that the ‘usual’ patient is different from years ago and requires a much higher level of care.”

“’Skilled nursing’ is a euphemism for ‘med-surg floor.’”

“The problem isn’t that RNs don’t want to work in LTC it’s that the LTC industry as a whole is an inhospitable environment for anyone to work in, nurse or otherwise…The industry is already so rootbound with rules and regulations that it is virtually impossible to function reasonably in this setting.”

“Nursing homes are no longer ‘rest homes’ but individual, sub-acute hospitals. Post-op orthopedic, cardiac, stroke care, along with rehab and wound care, bring with them outlandish amounts of regulations and paperwork. Add to that corporate financial officers who dictate the number of nurses and aides that can work each shift, no matter the acuity of care needed, and you have the recipe for what you find in nursing homes today…. A previous nurse mentioned 46 patients and one nurse on night shift. Of those 46, how many had orders for medications that required ‘30 minutes before (or after) meals,’ multiple insulins (long and short acting), multiple eye drops (administer individually with a wait between), multiple inhalers (also with waits)? Medicating ONE individual might mean 5–6 personal contacts! All of these must be recorded on the medication record and many must be documented on the patient’s chart.”

“Another unspoken issue is that nursing homes are not seen as a desirable workplace by young nurses or by high quality administrators. Lower pay and little room for advancement does not attract the best and brightest. Administrators walk a financial tight rope to keep the place profitable by keeping staffing at a minimum, which also does not lead to innovation or satisfied workers.”

There’s no doubt the quality in nursing homes varies widely. I’ve visited relatives in homes where residents were engaged with staff, music was playing, and there was an air of energy and care. And I’ve also been to a few that seemed ill-lit and foreboding, where there seemed to be few staff circulating among residents, and residents were mostly in wheelchairs in day rooms with TVs on, being watched by no one, or lined-up in hallways or rooms, one after the other, like a train waiting to go somewhere. I asked once what they were lined up for and was told they were waiting for the lunch room to open—in two hours’ time.

Span points out that new federal legislation has been introduced to increase RN staffing to 24 hours a day. But some nurses I’ve spoken with don’t feel that will happen. The for-profit corporations and their lobby are too strong and will block such legislation as being too expensive. As one commenter noted about the state of nursing care in nursing homes, “Is this an indication of how little we value the elderly or how greedy someone is?” Sadly, I think it’s both.

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Editor-in-chief, AJN


  1. hawkesbehawkesbe September 28, 2014 at 6:59 pm

    Reblogged this on My Blog and commented:
    Great post on this topic.

  2. Michele September 24, 2014 at 7:49 pm

    ALL nursing staff needs to know who “the powers that be”, so we may invite them to work a shift and see what we are NOT able to accomplish with so little time. I am staff development…. I can’t effectively train nurses who only have fleeting moments of time… And corporate who won’t bend on allowing training other than the regulated training… OR what is urgent…to company

  3. Christine Dileone September 24, 2014 at 12:38 pm

    Having a mother in long term care with Alzheimer’s, I have seen first hand, how the lack of staffing effects patient care, especially with those affected by dementia with behavior issues that tend to accompany this disease. Having an RN in the building who is covering ,multiple floors is simply unsafe. The LPN’s on the floor are “chained: to their medication carts and care is often provided by nursing assistants.

  4. JAN Lloyd September 24, 2014 at 10:31 am

    My husband was in a nursing home temporally after a CVA. The nursing care was nonexistent. He was totally continent ; the first thing they did was place him in depends because no one had time to help him to the bathroom. Medicine that was ordered Q8 hrs was given TID ,he fell trying to get up to go to the bathroom and fractured ribs and no one told me. PT saw him for 10-15 minutes and charged medicare for an hour. Speech therapy was done in a group….AWFUL. I am writing a book “Medical Homicide” that details the poor nursing care in hospitals and nsg homes in louisiana. He had AF and was not given an an anticoag…thus the CVA. e need to form a national committee of representatives from all over the country and address this issue with cry very poor nsg care in hospitals and msg homes. No one can fix a nsg problem but nurses.Janice Lloyd RN,MSN,FNP

    Date: Wed, 24 Sep 2014 12:40:42 +0000 To: janarm@hotmail.com

  5. Karen Simpson September 24, 2014 at 9:49 am

    I started my health career as an aide in a nursing home and was inspired to attend nursing school because I wanted to do more. Sadly due to the greed and short staffing I realized that even with and RN behind my name there was little I could do. I love geriatrics and caring for the elderly but cannot find an environment that supports the type of care they deserve.

  6. Tracey L. Connolly, RN, MSN, AGCNS-BC September 24, 2014 at 9:01 am

    I worked in a skilled nursing facility with a wonderful administrator. I went in thinking that I could make a difference, but the idealism didn’t last very long. The administrator tried increasing staffing above what is required by the state, but there was no change in patient outcomes. I was the inservice director and spent a lot of time explaining to the staff that they should not treat the increased staffing as a chance to relax a little, but that is exactly what happened. Patient satisfaction scores did not improve, the number of hospital readmission did not drop, and staff attendance did not improve. Without these metrics to validate the cost, the administrator was forced to drop the staffing levels back down.
    I am not sure if the staff was so exhausted that they couldn’t help themselves or if they did not understand what was necessary to maintain the increased staffing. In any case, just improving the staff-to-patient ratio was not the answer in our facility. Many of the employees have worked in LTC for many, many years. It is difficult to bring about change in this environment without an investment in training. As stated by others, the patient base in LTC has changed greatly over the last decade. When most of the staff have been there for many years they do not have the most up to date training and are resistant to doing anything ‘new’ or different.

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