Low wages, chronic staffing shortages and nursing staff turnover have contributed to higher transmission of COVID-19 in long-term-care facilities, experts said at a conference on preventing the spread of infections.

The pandemic exacerbated and exposed the precarious working conditions of nursing professionals across the country, according to panelists at the virtual event sponsored by New York Academy of Medicine and the Yale School of Nursing earlier this month.

“Increases in nurse-to-patient ratios have been connected with lower infection rates,” said Elana Kieffer, program officer at the academy’s Center for Healthy Aging. “Yet 83% of facilities are short-staffed.”

Higher rates of infection are also connected with staff working multiple part-time jobs, Kieffer said. The national mean salary for certified nursing assistants in nursing homes, who perform most patient-care duties under the supervision of licensed nurses, was $29,650 in 2019, the U.S. Bureau of Labor Statistics reported.

“Nurses working in nursing homes historically get paid significantly less than those working in hospitals,” said Dr. Michael Wasserman, a Southern California geriatrician and nursing-home patient-safety specialist. 

“It does require [nurses] to work in multiple facilities just to manage their bills,” said Evelyn Cook, a registered nurse who is associate director for North Carolina’s statewide program for infection control and epidemiology.

For nursing home residents, the consequences of caregivers having multiple jobs has been devastating. The National Bureau of Economic Research attributes 49% of COVID cases in nursing homes to staff movement between facilities. 

“The low level of pay and low status on the employment scale needs to change,” said Patricia Stone, a Columbia School of Nursing professor who specializes in the prevention of infections in vulnerable adults. “It would go a long way if we found a way to professionalize it, to invest in it and to find career paths to help these people so they can just be employed in one nursing home.” 

These pre-existing conditions, in addition to the pandemic, have caused more nurses to experience burnout.

“Hospital nurses were burned out and working in understaffed conditions in the weeks prior to the first wave of COVID-19 cases, posing risks to the public’s health,” a British Medical Journal study found in looking at 254 hospitals in New York and Illinois. “Such risks could be addressed by safe nurse-staffing policies currently under consideration.”

In August, the American Nurses Foundation reported 61% of nurses in long-term-care facilities felt overwhelmed and 50% felt anxious or unable to relax.

“I would say that at this point, maintaining resilience in the long-term care workforce has to be our top priority in both communities and organizations,” said Dr. Nimalie Stone, an infectious-disease specialist at the U.S. Centers for Disease Control and Prevention.

But nurses’ working conditions are not the only thing that needs to change. The spread of infections was a problem in nursing homes even before the pandemic, one that infection prevention training alone has not solved, panelists said.

“We’re seeing a bright spotlight that this pandemic has placed on the critical role of infection preventionists,” said Nimalie Stone.

The Association for Professionals in Infection Control and Epidemiology defines infection preventionists as workers who help identify and prevent the spread of germs. They educate healthcare workers on everything from proper handwashing to the right ways to use personal protective equipment.

Nursing homes with infection preventionists who underwent specialized training can be up to 13 times more likely to have lower infection rates, Kieffer said.

So why don’t more nursing homes have these dedicated specialists?

Wasserman said legislation is needed to mandate infection preventionists in all of these facilities, as California did last September. He said their duties must be enshrined in law  to ensure they are not asked to perform other tasks.

“In nursing homes, these people are being pulled in multiple directions,” he said. “But in a pandemic they can’t be.”