Publication date: Jul 02, 2026
Examining nursing home staffing trends throughout COVID-19 provides critical insights for developing equitable workforce policies and resource allocation strategies. To examine differences in nurse staffing levels across community distress levels, focusing on the temporal trends from 2019 to 2023. This longitudinal observational study used random intercept mixed-effects models to analyze retrospectively collected data from 15,042 certified nursing homes. Data were merged from 2019 to 2023 Nursing Home Compare, 2019 to 2021 LTCFocus, and the 2016 to 2018 Distressed Community Index (DCI). Outcomes were case-mix adjusted hours per resident day (HPRD) for registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs). Predictors included DCI quintile and calendar quarter interactions, adjusting for bed count, ownership, chain affiliation, dementia unit status, payer mix, and five-star rating. RN HPRD were lower in nursing homes in more distressed communities, with the fifth and first quintile HPRD gap widening during the pandemic (2020 Q2 = -0. 187 [-0. 220, -0. 155]; 2020 Q3 = -0. 201 [-0. 234, -0. 169]; 2020 Q4 = -0. 211 [-0. 244, -0. 179]). LPN HPRD were highest in the most distressed communities, with the fifth and first quintile gap narrowing post-pandemic (2021 Q4 = 0. 050 [0. 022, 0. 077]; 2022 Q4 = 0. 036 [0. 009, 0. 063]; 2023 Q4 = 0. 027 [0. 000, 0. 054]). CNA HPRD were lowest in the most distressed communities and varied inconsistently across communities, with post-pandemic levels falling below pre-pandemic baselines. The pandemic widened RN staffing gaps in distressed nursing homes, forcing LPN substitution, while CNA staffing fell below pre-pandemic levels. Addressing these compounding shortages requires targeted financial incentives and equitable, data-driven staffing policies. Distinct staffing patterns across DCI quintiles call for systematic investigation into appropriate staffing levels and targeted policies to ensure quality care in under-resourced nursing homes and inform public health emergency preparedness.
| Concepts | Keywords |
|---|---|
| Covid | COVID-19 |
| Nurses | Healthcare disparities |
| Pandemic | Neighborhood characteristics |
| Nursing homes | |
| Workforce |
Semantics
| Type | Source | Name |
|---|---|---|
| disease | MESH | COVID-19 |
| drug | DRUGBANK | Dichloroisoproterenol |
| disease | MESH | RNs |
| disease | MESH | included |
| disease | MESH | bed |
| disease | MESH | dementia |
| disease | MESH | star |
| disease | MESH | emergency |