Longitudinal Associations of Staff Shortages and Staff Levels with Health Outcomes in Nursing Homes

Ming Chen, James S. Goodwin, James E. Bailey, John R. Bowblis, Shuang Li, Huiwen Xu

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Objectives: To examine whether facility-reported staff shortages and total staff levels were independently associated with changes in nursing home (NH) outcomes in 2020. Design: Longitudinal cohort study. Setting and Participants: A total of 8466 NHs with staffing and outcome data. Methods: This study used NH COVID-19 Public File (2020), Nursing Home Compare (2019-2020), and Payroll-Based Journal data (2019-2020). Outcome measures included the percentage of long-stay residents in a facility with declines in activities in daily living (ADLs), decreases in mobility, weight loss, and pressure ulcers in 2020 Q2, 2020 Q3, and 2020 Q4. Independent variables were whether NHs reported any shortage of aides or licensed nurses and total staff hours per resident day (HPRD). Separate 2-level (NH, state) Hierarchical Generalized Linear Mixed models examined the association of facility-reported shortages and staff hours with key NH resident outcomes, controlling for NH characteristics and COVID-19 infections. Results: The weekly percentage of NHs reporting any staff shortage averaged 20%. Total staff HPRD increased slightly from 3.7 in 2019 to 3.8 in 2020. Health outcomes were stable during 2019 and 2020 Q1 but worsened substantially starting in 2020 Q2. For example, the percentage of residents with mobility loss increased from 16.2% in 2020 Q1 to 27.9% in 2020 Q4. Facility-reported staff shortages were associated with an increase in the proportion of residents with an ADL decline (0.54 percentage points), mobility loss (0.80 percentage points), weight loss (0.22 percentage points), and pressure ulcers (0.22 percentage points) (all P < .01). Total staff HPRD was not associated with changes in any outcomes (all P > .05). Conclusions and Implications: NHs reported worsened health outcomes among long-stay residents in 2020, with worse outcomes found among facilities that reported staff shortages but not among those with lower total staff levels. Facility-reported shortages provide important quality information during the COVID-19 pandemic.

Original languageEnglish (US)
Pages (from-to)1755-1760.e7
JournalJournal of the American Medical Directors Association
Issue number11
StatePublished - Nov 2023


  • COVID-19 pandemic
  • Staff shortages
  • health outcomes
  • staff hours per resident day

ASJC Scopus subject areas

  • General Nursing
  • Health Policy
  • Geriatrics and Gerontology


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