National Skilled Nurses Week 2024 – Advocacy Guide

Their main tasks include assisting their patients with activities of daily living such as eating, bathing, hygiene, helping patients move around, stocking medical supplies, checking patients’ vital signs, dressing wounds, logging information, and communicating with patients, their families, and healthcare teams.

However, the functions of their role go beyond performing clinical tasks. In many cases, they become the primary source of emotional support and social interaction in a patient’s life. Without a doubt, these healthcare workers play a unique and crucial role in society. However, they are often underappreciated.

Working conditions at long-term care homes have become more well-known since Covid-19, thanks to the countless nurses and other healthcare workers who shared stories of exhaustion, grief, and burnout on social media. While the pandemic was an exceptional situation, many of the grievances highlighted by healthcare workers were present long before 2020 and are ongoing in facilities nationwide.

National Skilled Nursing Week (May 12-18, 2024) is a time to celebrate CNAs, LPNs, and nurses and spread awareness about the enduring challenges they face in the workplace. 

“There’s a difference between skill and licensure,” says Dr. Rhonda Collins, nurse leader and advocate. “And when we look at staffing, the CNA is such a critical part of that [team] because of their skills.”

In honor of this week, we will explore some of the pressing workplace issues at long-term care facilities and potential solutions that healthcare leaders should consider.

The Upsides 

In spite of challenges, there are some truly positive aspects to working in long-term care environments that are hard to find in their environments.

Firstly, there are abundant open positions in long-term care, which can be advantageous for new entrants to the healthcare sector who want to gain experience. In this market, job seekers can also be more selective about where they want to work and more assertive about what perks and benefits they can expect from employers.

Beyond ease of entry, work in skilled nursing can be very fulfilling. Providers at long-term care facilities can get to know patients deeply and develop relationships with them. For many healthcare workers, this continuity of care relationship provides a source of meaning, motivation, and purpose that can be more elusive in ERs, clinics, and other healthcare environments.

The sense of gratification that comes from actively helping improve a patient’s quality of life in their older adult years can be another fulfilling aspect of skilled nursing work.

“There is so much teaching that goes on in skilled nursing to enable the family to care for the patient,” says Dr. Collins. “And I think that that’s very rewarding to be able to have such an impact in a patient’s life, to be able to help them understand how to care for themselves [and help] the family [learn] how to care for them.”

Nursing home staff who have high levels of personal accomplishment have been reported being more likely to give care focused on empathy and respect for those with disabilities. And studies have shown that nurse engagement, which refers to their degree of commitment, enthusiasm, and the dedication they feel to their job, is positively associated with their perceived quality of care from the patient’s perspective. So, when nurses feel like they’re doing their jobs well, they are happier and more driven to keep up the good work.

“​​The work that itself has to be satisfying… We have to feel like our lives make a difference, and if we don’t feel that way, it’s very hard to stay committed,” says Dr. Collins.

Unfortunately, working conditions are hardly ever optimal for nurses or CNAs, which inhibits their ability to sustain their mental health and to do their jobs well. 

The Downsides

Typical nursing issues, such as the expectation to work overtime, short staffing, and burnout, tend to be more exaggerated in long-term care settings. 

According to a survey from the American Nurses Foundation, when respondents were asked whether they consider their work environment healthy or positive, long-term care facilities reported the lowest scores across all other care settings.

In general, low morale in the workplace can be a result of unclear expectations and poor leadership. But in healthcare environments, toxic workplace culture also ties back to fundamental factors such as inadequate resources and lack of staff, space or time to adequately care for patients.

Since patients at long-term care facilities tend to have complex healthcare needs, cognitive impairment, and loss of physical function, working in this environment can be demanding at baseline. Adding understaffing into the equation pushes many healthcare workers past their capacities and can result in burnout.

One study notes that burnout among care aides has not been studied as widely as burnout among other healthcare workers in nursing homes, so statistics are limited, but undoubtedly, the problem is significant.

The article defines burnout as “a prolonged response to chronic emotional and interpersonal stressors on the job” that can be organized into three categories: 

• Exhaustion (feelings of emotional and physical depletion)
• Cynicism (a negative, detached response to the job)
• Reduced professional efficacy (feelings of incompetence and a lack of achievement at work)

Many healthcare workers have been driven out of the sector due to poor working conditions and burnout, worsened by Covid. The domino effect has caused further shrinkage to the candidate pool and exacerbated recruitment and understaffing issues by proxy.

Consequently, healthcare workers are also increasingly expected to work overtime. Three out of four nurses are required to work overtime at least once a week at long-term care facilities compared to 58 percent of nurses in other settings, according to the American Nurses Foundation survey.

The topic of overtime has become an increasing point of contention in the healthcare sector with some states even opting to ban mandatory overtime for nurses, such as New York, which passed such a law last July. However, the majority of states do not have these limitations in place.

Regardless of state laws, asking nurses and CNAs to work overtime is a band-aid solution to a larger problem. Piling extra hours on top of staff already burdened from working in short-staffed departments is a recipe for burnout.

This practice is not only bad for healthcare workers; involuntary overtime has also been shown to negatively affect patients’ health outcomes.

One CNA expresses the effect of the constant shortage of time on healthcare workers in a study on nursing home staff turnover: “You get frustrated because you can’t give the care that they deserve, and so it kind of makes you feel like, why am I even doing this…I don’t even have the time to comb this lady’s hair like she likes it, or I don’t have the time to make her bed as well as she’d like it… it kind of just hurts your feelings because you know this is what makes these people happy…”

This inability to meet patients’ needs can disenfranchise and distress healthcare workers and degrade their sense of accomplishment and motivation.

On top of everything, employees at long-term care facilities also witness more death than those who work in clinics and non-emergency care environments, which also makes these providers more prone to emotional injury and chronic grief.

The challenges that skilled nursing professionals face should mean that they are paid generously, but this is not the reality.  “I think for all of nursing, compensation remains an issue, but especially in some of the skilled nursing facilities,” says Dr. Collins.

According to data from Indeed, the average hourly wage for RNs at skilled nursing facilities in the U.S. is $30.66—a substantial 25% lower than the overall average hourly wage of RNs in the U.S., which is $43.70.

CNAs make about $20 to $21 per hour on average (regardless of their employment setting.) Considering the minimum living wage in the U.S. was $25 per hour in 2023, there is plenty of room for improvement for CNAs across all settings.

The burden of insufficient wages on top of the expectation to work in understaffed environments adds to the difficulty for healthcare workers to continue sustaining themselves, contributing to high rates of turnover; nearly half of nursing home providers said their workforce situation worsened between 2022 and 2023, according to data from the American Health Care Association and National Center for Assisted Living.

According to the 2024 Skilled Nursing Outlook 2024 survey, recruitment and retention is the most significant concern among healthcare leaders, with half of respondents reporting it as the biggest challenge.

This combination of factors creates a vicious cycle that is detrimental to healthcare workers, patients, and even their employers:

• Under-resourced environments and understaffing burden healthcare workers and eventually lead to burnout, undermining patient health outcomes
• Poor compensation and lack of resources lead to higher levels of turnover, perpetuating understaffing
• Higher turnover also translates to unnecessary costs in recruitment and training for healthcare organizations, which could be better spent on compensating current employees and supplying resources within care centers

Problems with skilled nursing environments are not unsolvable. According to Dr. Collins, change starts at the root: with organizational culture. “The culture of the company or the culture of the department is all defined by how leadership sets the tone,” says Dr. Collins. “Culture doesn’t just happen. It is a deliberate choice.”

As one 2022 study purports, although nursing home staff do mention better wages as a factor that could decrease turnover, appreciating and supporting staff is paramount, suggesting that a multi-pronged approach is necessary. 

Examples of deliberate changes to organizational culture include:

• Evaluating organizational slack (i.e., adequate staffing, physical space, and sufficient time to deliver quality care) and making improvements where possible 
• Delivering adequate training and acclimating new staff to patients’ specific needs and preferences
• Expanding sick leave and mental health policies to promote the mental and physical health of healthcare workers and prevent burnout
• Offering counseling for grief and other mental health concerns (either by expanding insurance coverage to cover counseling or by employing a psychologist on staff)
• Providing essential supplies for workers (e.g., PPE, virus testing policies, etc.)

Upgrading technology can also be a boon to under-resourced skilled nursing facilities. Kontact.io, where Dr. Collins is chief nursing officer, offers Internet of Things (IoT) solutions such as smart wrist bands for patients, smart badges for staff, equipment tracking and other software solutions that can minimize time wasted on bottlenecks, saving more time for patient care.

As the American Nurses Foundation says, “[Improvement] begins with listening to nurses and fully engaging them as true partners in solving workplace problems … It begins with truly listening to nurses’ experiences and committing to investing in new ways of doing things and shifting how dollars are spent.”

Real change will take time, intention and commitment on behalf of long-term care employers. In the meantime, words of affirmation can go a long way in lifting skilled nursing providers’ spirits.

“People thrive on reward and recognition. It keeps us motivated, and I think that it’s really important in these high-stress, demanding jobs that folks be recognized,” says Dr. Collins. “I do think that … just taking a moment to sincerely tell people what they mean to the facility and what a difference they’ve made and highlight their work is critically important.”