Assuring the adequacy of staffing of long-term care, strengthening the caregiving workforce, and making long-term care a career destination of choice: from mission impossible to mission critical?

NC Med J March/April 2010, Volume 71, Number 2 Nationally, over 3 million certified nursing assistants and licensed nurses work in long-term care (LTC). Of these 3 million providers, about 2.5 million are certified nursing assistants (CNAs) and the remaining 500,000 licensed nurses are evenly divided between licensed practical nurses (LPNs) and registered nurses (RNs).1 With the aging of our population, experts estimate that the demand for this workforce will double in the coming decades, requiring up to 5 million direct care workers, 868,000 RNs, and 231,000 LPNs nationally.2 In 2007, an estimated 109,900 full-time equivalent direct care nursing positions at nursing facilities across the United States were vacant; approximately two-thirds of the vacancies were for CNAs and one-third for licensed nurses. National turnover rates among CNAs, LPNs, and RNs remain high, most recently estimated at 66%, 50%, and 41% respectively.3 The situation in North Carolina is even grimmer: annual turnover rates for nursing staff are conservatively estimated at 86%,3 with CNA turnover most recently estimated at over 100%.4 Supply of and demand for advanced practice nurses (APNs) practicing in LTC (board-certified nurse practitioners and clinical nurse specialists) is not currently tracked systematically, but studies demonstrate their value in managing chronic and acute illnesses in nursing homes, as well as in helping staff integrate quality improvement approaches into routine care.5,6 The growing evidence of APN effectiveness in LTC at both the patient and organizational level has led to calls to include APNs in nursing home staffing standards.7 In addition to providing primary care to LTC residents, APNs have shown positive impacts when providing acute or transitional care to older adults, serving in an educational role to residents, families, and staff, and providing consultation to staff or organizations on patient care and systems level issues.8 The sheer size of the gap between what we have and what we need to ensure adequate nurse staffing in LTC is staggering. Given the high turnover and growing need for a higher skill set among the LTC nursing workforce, simply enticing larger numbers of personnel to enter the field will not suffice to ensure adequate numbers of competent LTC nursing staff in the coming decades. Three key challenges in the LTC work environment need urgent attention before incentive programs to address the current shortfall in personnel will have any lasting effect: