Working, or Unable to Work, the ‘Most Dangerous Jobs in America’

On February 28, 2020, a nursing home resident in Washington State tested positive for COVID-19. Within weeks, the virus had spread to 100 residents and 50 staff, as well as 16 visitors. More than half of those individuals required hospitalization and 34 residents died.

This shocking outbreak revealed how rapidly COVID-19 can spread in congregate settings. Tragically, it was only a hint of the catastrophe to come. The New York Times reports that, as of Jan. 12, 2021, the virus has infected more than a million people in nursing homes and other congregate care settings since that first outbreak—and caused more than a third of the U.S.’s COVID-19 deaths.

This has been a horrifying time for long-term care residents, families and staff, primarily certified nursing assistants (CNAs) and residential care aides. These workers provide direct, hands-on care and are disproportionately at risk of contracting COVID-19 and suffering adverse outcomes due to their role and the health inequities they face (workers are predominantly people of color).

Overstretched and Endangered

As a result, countless CNAs and residential care aides have left their jobs, some directly forced out by the virus: according to Centers for Medicare & Medicaid Services (CMS) data, nearly 600,000 staff in nursing homes had contracted COVID-19 by Dec. 20, 2020 (suspected or confirmed) and 1,268 had died. Many have taken time off to quarantine, stay home with children, care for ill family members or for other reasons. Still others have opted to leave the “most dangerous jobs in America” altogether.

And long-standing recruitment and retention challenges had already created a staffing crisis in these settings. Nursing assistants supported an average of 13 residents per shift prior to the pandemic, while many cared for 16 or more residents. Such untenable workloads are likely even heavier now, as one in five nursing homes grapples with a shortage of nursing assistants. Although similar statistics are not available for assisted living communities and other congregate settings—which are state-regulated—there is no doubt that they are also struggling with the same cycle of understaffing and outbreaks. 

Some immediate staffing challenges may be offset by a decline in the numbers of long-term care residents (due both to resident deaths and concerns about safety). Of the record number of jobs that were lost in December 2020, 5,000 jobs were in nursing homes and 6,000 in residential care for older adults, which reflects this decreased demand for services as well as the worker turnover described above. But even so, there remains a critical need to strengthen this workforce—to fill staffing vacancies, manage the risk of outbreaks, and provide daily care for all those who rely upon it.  

Responding to the Crisis

States and employers can mitigate the immediate crisis through a range of short-term actions: expediting workers’ access to personal protective equipment (PPE), testing and vaccination; implementing hazard pay and paid sick leave and family and medical leave policies; improving access to childcare and other employment supports; disseminating targeted training modules; and supporting workers in managing the stress and grief of the current moment. These strategies have been implemented in piecemeal ways and to varying degrees, reflecting the lack of coordination across the long-term care system.

To address the workforce crisis in long-term care settings we need high-quality jobs—quick fixes will not stem the tide of turnover and job vacancies.

In addition, a number of states have created nursing home strike teams that can be dispatched to manage outbreaks, including by replacing staff who are on sick leave. Another key response has been to reduce barriers to entry into nursing assistant jobs, including by implementing reciprocity agreements with other states (for already-certified CNAs) and waiving the minimum training and certification requirements for new hires.

(The latter approach was promulgated at the federal level by CMS as part of a set of regulatory waivers designed to help nursing homes cope with the pandemic. Although an important stop-gap, this waiver has raised serious concerns about the impact on care quality and about how temporary nurse aides will be managed post-pandemic.)

Transforming the Direct Care Workforce

But what is most needed to address the workforce crisis in nursing homes and other long-term care settings are high-quality jobs—otherwise these quick fixes will not stem the ongoing tide of turnover and job vacancies. Job quality in direct care is not just about compensation, although these workers desperately need a living wage and adequate benefits; it also encompasses quality training, supportive supervision, respect and recognition and meaningful career development opportunities.  

In PHI’s new report, Caring for the Future: The Power and Potential of America’s Direct Care Workforce, we lay out a range of strategies for improving direct care job quality and stabilizing the workforce—from reforming long-term care financing to raising the wage floor for workers to strengthening training standards and delivery systems and more.

One key strategy is to develop more rungs in the direct care career ladder. Some workers are on a path to licensed nursing and other professional roles—but many others thrive in direct care and/or do not have the requisite time or financial resources to pursue a professional path. Long-term care leaders should create and evaluate advanced roles that build on workers’ existing competencies and experience—such as advanced roles supporting entry-level workers or specializing in specific conditions or care transitions.  

With better training, compensation, advancement opportunities and such, workers will be more likely to remain in their jobs. By investing in and elevating the workforce, the long-term care system will, in turn, be better equipped to provide essential daily care for millions of older adults and individuals with disabilities. Transforming direct care jobs—to create a stronger, more stable workforce—is also a critical step toward preventing future crises from reaching the catastrophic scale that we have witnessed with COVID-19.   

Kezia Scales, PhD, is director of Policy Research at PHI. She is based in Durham, NC.