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Nursing Home Understaffing in the US: Causes, Consequences, and Coping

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Understaffing in nursing homes has increasingly become an issue in the United States with over 90% of nursing homes reporting shortages in staff. This is an issue that effects the patients, families, staff, and the nursing homes as a whole. This creates further health concerns for those involved. Labor costs are often attributed to this issue despite research showing it costs more to understaff. Through research and experimentation, it can be seen there are many solutions to this growing problem. This paper will examine the previous research to establish potential reasons and effects of understaffing while also addressing current ways in which facilities have addressed this topic.

Understaffing is a topic of recent focus with the current and projected increase in elderly adults within nursing homes in the future. The increase in cases of understaffing has caused more attention and led to further strides in the research involving understaffing, reasons for it, and potential influences this has on nursing homes and nursing facilities. Recent research revealed that 90% of nursing homes in the United States are understaffed and there is an increase in proposals on what is an acceptable resident to staff ratio within these facilities (Hyer, Temple, & Johnson, 2009). Recent research is also suggesting there could be a correlation between understaffing and wrongful death among residents (Levin, & Rushing, 2008). Wrongful death can occur from any lack of supervision or care of a resident within a facility (Levin, & Rushing, 2008). Finances are often attributed to this short staffing but further examination shows there are more costs than just the assumed labor costs (Burns, Hyde & Killett (2016). There is evidence that proposes the expected marginal benefit of hiring more people will outweigh the expected marginal cost for nursing homes to hire more people. With these factors taken into consideration we must ask, what is the social work profession as well as nursing homes and organizations doing to combat this social issue? These factors included also influence the mental and physical condition of the workers who are working under these conditions (Aleshin, 2014).

This paper will examine the previous research to establish potential reasons and effects of understaffing while also addressing current ways in which facilities have addressed this topic. Further examination will show the effects understaffing has on both the patients and the workers within the nursing home. We will also look at financial factors and misconceptions behind them that has led to this short staffing issue. We will also address what the social work profession is doing in order to address this issue.

Understaffing in Nursing Homes

There has been a variety of studies addressing understaffing within nursing homes and its effect that it has on both the patients and the workers. Understaffing is defined as a shortage in workers leading to patients not receiving proper care (Hefner, 2002). It has been proposed that more than 90% of nursing homes are understaffed in the United States. Studies showed that patients in nursing homes with the least number of workers were more likely to suffer from bed sores, malnutrition, weight loss, dehydration, pneumonia and blood borne- infection (Hefner, 2002). As the life expectancy increases, people require more medical assistance and attention within the nursing home (Preshow, Brazil, McLaughlin, & Frolic, 2016).

A factor of understaffing that affects the patient is inability or lack of communication through staff to provide the care needed for patients. A study proposed that informed decision-making that included both nursing staff, doctors, patients, and family, led to better care within the home. When staff was limited it led to miscommunication and what some residents called questionable care (Preshow, Brazil, McLaughlin, & Frolic, 2016). It was proposed that nurses also get comfort in being able to speak to their fellow nurses and allowed for them to consider ethical dilemmas. With shortness of staff it showed that this time was often not available in order to do so (Preshow, Brazil, McLaughlin, & Frolic, 2016). Due to understaffing, many states such as Ohio and California have adopted minimum staffing standards in an effort to combat this (Chen, Min, Grabowski, & David, 2015). A minimum staffing standard was established by examining the minimum number of hours nursing staff worked in nursing homes on a daily basis.

Patient Issues

The main focus in any nursing home, is the safety and care of the patients that are being housed within. Research is showing that safety and care is often times at jeopardy due to understaffing. An area of recent focus and legislation involves nurse to patient ratio. Nurse to patient ratio shows how many staff there are compared to patients, a ratio of 1:1 shows 1 nurse per 1 patient while a ratio of 50 indicates 1 nurse per 2 patients. Research is showing that when the ratio is lower, indicating more staff per patient, nurses felt they were more safe practitioners (Louch, G., O’Hara, J., Gardner, P., & O’Connor, D. B. (2016). Inversely, when the ratio was higher, they felt they worked safer with the patients and showed higher levels of conscientiousness and emotional stability. When the work load for a nurse is higher we see that prevalence of infections, such as pneumonia and urinary tract infections, failure to rescue, and shock or cardiac arrest (Welton, 2007).

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Increased work load directly correlates with wrongful death and its increased rates in nursing homes. Wrongful death is any form of neglect or malpractice by one person led to the death of another. Since the early 1990’s the United States has seen an increase in elderly admitted into nursing homes. Since this happened, the number of claims per nursing home bed has tripled (Konetzka, Park, Ellis, & Abbo, 2013). With the higher number of patients and not enough nurses, staff are required to work significantly more hours which then influences the quality of their care. It was found that patients found their care more favorable if they were involved in the conversation about their care as well as able to put forth their input. When nurses have more hours and higher workload, they are less likely to collaborate with their patients which decreases their comfort and care (Aleshin, 2014). Within nursing homes, we see that understaffing can pose many issues for the patient and influence their safety and overall care.

Staff Issues

Large amounts of research on understaffing in nursing homes focuses on the effects it has on the patients but further research suggests the staff itself is being heavily affected as well. Understaffing creates ethical issues within the nurses themselves. Nurses feel when understaffed they have to prioritize their patients leading to neglect of others and inability to include patients in their own treatment (Aleshin, 2014). Prioritizing patients causing neglect can also lead to malpractice lawsuits against the individual as well as the organization itself which possesses financial implication that will be address later in this paper. With the lack of staff came the issue of not being able to know their patient on a personal level which many said was a meaningful aspect to their job. This lead to feelings of inadequate care which influenced a troubled conscience and increased stress levels within the staff (Preshaw, Brazil, Mclaughlin, & Frolic (2016). We also see that in homes that were understaffed, 90% of staff were willing to break confidentiality if it meant upholding their other responsibilities for their patients (Preshaw, Brazil, Mclaughlin, & Frolic (2016). Lack of confidentiality is alarming because it is vital within the nursing home the for both nurses and their patients yet staff are sharing details of patients with other nurses in order to provide the care that they need. Nursing homes that reported overworked staff also showed indications of ageism, or a type of prejudice due to age. It was seen from both perspectives, the nurses and the patients that were at these nursing homes (Preshaw, Brazil, Mclaughlin, & Frolic (2016). It can be seen that elevated levels of stress within these high workload staff members. Stress is a process in which environmental demands strain an individual’s capacity, this can cause psychological and biological issues leading to illness and other health risks (Salleh, 2008). When illness is contracted in the workers, it can be spread to the easily susceptible patients they are working with on a daily basis. All of this shows the heavy impact it can have on the workers in an understaffed environment.

Cost of Staffing

One of the main reasons for understaffing within nursing homes is the expected cost of labor. Labor costs for registered nurses in the United States are around $65,000 annually per worker which depending on if the nursing home is non-profit, government funded, or for profit, can be a lot of money (Di Giorgio, Filippini, & Masiero 2015). This being said, it has been suggested that the cost associated with understaffing is greater than if the nursing home were to hire more employees. As stated previously, wrongful death and neglect are issues within the nursing home when understaffed. This causes lawsuits, court fees, medical expenses, and lawyer fees to all be placed on the nursing home itself. On average every year there are over 1800 wrongful death and neglect lawsuits in nursing homes. That’s about 1 per home each year. It is estimated that the final total cost in a lost suit can be between $755,00-$943,750. With this being the case, the expected benefit of hiring more staff, less wrongful death, neglect lawsuits and settlements, could outweigh the expected cost of hiring the new staff. Statistics show that nursing homes will potentially save money in the end by having more staff and a higher staff to patient ratio.

Implications for Social Workers

The research suggests that nursing homes need to make changes in order to benefit the patients, staff, families, and the nursing homes as a whole. To do this social worker must work on the macro and micro levels. Social workers must advocate to implement an affective staff to patient ratio in order to legally avoid understaffing. Social workers must also be vocal within the nursing homes themselves in order to influence the hiring of more workers. Social workers must also be more willing to incorporate the patient, staff, and family into the treatment plan. Research suggests that by incorporating all parties involved in the treatment, the level of care and effectiveness is increased. This would also significantly reduce the severity of wrongful injury and frequency of wrongful death.

Within schools and higher education institutions, this problem must be addressed in order to provoke interest for students and aspiring social workers to want to be active in working in nursing homes to reduce understaffing. Nursing homes themselves need to open up networking outlets to increase the number of applicants and potential workers. With research suggesting that the field is growing about 16% over the next 10 years, there should be little issue obtaining enough workers to accommodate an affective staff to patient ratio. Through advocating, raising awareness, and increasing marketing for nursing home jobs, understaffing can be significantly reduced. Also, through the incorporation of all parties within the care of the patient, social workers can increase the quality of care and reduce the likelihood of wrongful death.


Through research and experimentation, we can see the lasting effects of understaffing within nursing homes. Examination of the research also shows the benefits of which can be had by appropriately staffing. Understaffing is a detriment to the quality of care for the patient, the ability for self-care for the staff, and the functioning of the nursing home as a whole. It can be seen that there are misconceptions about the cost of properly staffing despite evidence proposing there is more to gain by hiring more staff. An understaffed nursing home paves the way for neglect, further ailments, and wrongful death. This problem causes ethical dilemmas within the nursing home, creating conflict for many of the staff. Families with patients in the nursing home are also hindered in their pursuit for the best care for their loved ones.

Research proposes relatively simple solutions for this epidemic. With 90% of nursing homes experiencing understaffing and recognizing the issue, citizens and workers must question why more hasn’t been done to combat it. While social workers should be advocating to correct this form of malpractice, it is also up to the people to combat this social issue. Through education, advocating, and implication, understaffing can be significantly reduced throughout the United States. This paper acknowledges that the United States is lacking in this field and can learn more from other nations in order to correct this. Research is addressing this topic in greater detail in an effort to make more strides to solve this issue.


  1. Aleshin, O. (2014). Understaffing puts strain on all. Lamp, 71(10), 14-15.
  2. Burns, D. J., Hyde, P. J., & Killett, A. M. (2016). How Financial Cutbacks Affect the Quality of Jobs and Care for the Elderly. Industrial & Labor Relations Review, 69(4),991-1016. doi:10.1177/0019793916640491.
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  7. Louch, G., O’Hara, J., Gardner, P., & O’Connor, D. B. (2016). The daily relationships between staffing, safety perceptions and personality in hospital nursing: A longitudinal on-line diary study. International Journal of Nursing Studies, 5927-37. doi: 10.1016/j.ijnurstu.2016.02.010.
  8. Preshaw, D. L., Brazil, K., Mclaughlin, D., & Frolic, A. (2016). Ethical issues experienced by healthcare workers in nursing homes. Nursing Ethics, 23(5), 490-506. Doi:10.1177/0969733075576357.
  9. Salleh, M. R. (2008). Life Event, Stress and Illness. The Malaysian Journal of Medical Sciences: MJMS, 15 (4), 9–18.
  10. Welton, J. (2007) “Mandatory Hospital Nurse to Patient Staffing Ratios: Time to Take a Different Approach ‘OJIN: The Online Journal of Issues in Nursing. Vol. 12 No. 3, Manuscript 1.

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