That was one warning from a panel of nursing experts who spoke during a KFF-hosted webinar late last week on strikes, shortages and staffing requirements.

“All of the healthcare system, all kinds of healthcare workers, are feeling this kind of stress right now,” not just the nurses Americans typically see on picket lines, said Bianca K. Frogner, director of the University of Washington’s Center for Health Workforce Studies.

The Kaiser Permanente threat, which followed a real and massive three-day strike earlier in October, won non-medical staff at Kaiser’s facilities major wage gains and staffing concessions alongside their frontline peers.

Increasingly, unions representing nursing home workers have been spearheading strikes or pickets for their therapists and support staff members, who say they too are being squeezed by chronic understaffing.

“There are clear signs of stress within the healthcare workforce, with shortages, strikes and burnout,” said webinar moderator Larry Levitt, executive vice president for health policy at KFF.

While he acknowledged healthcare is often recession-proof, Levitt said the pandemic employment shifts were different. And recovery hasn’t been easy, with certain sectors and parts of the country still limiting access to care because they don’t have enough staff. 

“We have many sectors in the healthcare space that are feeling the crunch of trying to find workers to fill the slots,” added Frogner, lumping long-term care in with behavioral health and primary care as the three sectors most in need.

She attributed much of the pain to a “maldistribution of workers” that has left rural providers and underserved communities with the greatest need. Nowhere might that be more apparent than in rural nursing homes, speakers noted.

‘Scary’ defection plans

Gretchen Berlin, RN, senior partner at McKinsey & Company, has studied nurse sentiment since the start of the pandemic. One of the “scary” constants of healthcare staffing over the last three years is the 25% to 30% of nurses who’ve told McKinsey on multiple surveys that they plan to leave the profession.

Though it has moderated since the heart of the pandemic, nursing turnover is still hovering around 22% annually across settings, about 3% to 6% higher than before COVID, Berlin said.

“We project these trends will continue to lead to a shortage,” she said. “We could be short up to 20% of what we need by 2025.”

She noted the propensity to turn away from nursing jobs is a global phenomenon, and that while more immigration could help, it won’t be a cure-all, even if reform happens in this Congress.

Alice Burns, associate director of the Program on Medicaid and the Uninsured for KFF, said long-term care employment is still 10% below pre-pandemic levels, a fact that sector advocates have bemoaned even as federal regulators push a first-ever national staffing minimum for nursing homes.

Burns said nursing homes’ broader care needs, where staff may have to do anything from changing a catheter to giving an IV or feeding a resident dinner, can make it more difficult to attract and retain workers.

“That’s a really different skill set, and then another difference is the payer mix, over half of the expenses are paid by Medicaid and over 25%, people are paying out of their own pocket,” she said. “That really places this downward pressure on payment rates, which puts downward pressure on wages.”

By fostering a cultural shift toward home- and community-based services, some states also have made it more difficult for nursing homes to recruit and retain workers because both sectors are drawing from the same pool.

However, increasing pay rates (with Medicaid boosted by extra federal matching dollars through the pandemic) and building career ladders have helped.

Frogner, while backing the intent of staffing ratios and their ability to improve patient care and worker satisfaction, said they will undoubtedly create new tension between sectors as they battle for the same would-be workers. 

“The problem is, where is the supply of workers when you put those ratios into play,” she said. Ratios will create more movement and competition between hospitals and nursing homes, but if skilled nursing staffing remains low, that will exacerbate patient waits or backlogs in acute settings.

Growing demand for home health workers is also drawing staff away from long-term care  facilities, and when they capture new workers, they’re not doing a good enough job keeping them.

“We’re seeing people move in and out of these jobs that have low barriers of entry,” Frogner said. “Once they’re in there, these workers are understandably looking around and asking, ‘OK, which job gives me the next benefits beyond wages? … Are there jobs that are a little bit easier and maybe a little more fulfilling in other sectors?’”

Join us on Tuesday, Nov. 14, starting at 10:30 a.m. ET and earn up to three CE credits while you learn how to attract workers to a modern careforce, budget for staffing over the last few weeks of the year, and better understand the role independent workers can play.

Register here, and learn more about the three sessions below:

Session 1 at 10:30 a.m. ET

Modern careforce: What they’re looking for and current trends

During this webinar, sponsored by KARE, you will:

•  Uncover the potential of AI in workforce recruitment and retention.
•  Gain a deeper understanding of where you can derive maximum value and engagement from your workforce as you build both traditional and non-traditional benefits programs.
•  Discover how to create and sustain a robust careforce through third party staffing.
•  Equip yourself to dispel the myths surrounding caregivers true preferences from their employers.

Speakers include Evan Kuo, regional vice president at KARE; Catie Ramp, president & CEO at Georgia Senior Living Association; and Serina Durrah, vice president of operations at Phoenix Senior Living.

Session 2 at 12:00 p.m. ET

In this session sponsored by Intelycare, you will learn how to:

• Best manage staffing spend in the final 6 weeks of the year
• Budget appropriately for this high-demand period
• Position their facilities for a solid start to 2024

Speakers include Landa Stricklin, director of clinical consulting, Richter Healthcare Consulting; Jennifer Richter, president & CEO of Richter Healthcare Consulting; and Sean Carney, vice president of client Services for Intelycare.

Session 3 at 1:30 p.m. ET

How independent workers are supporting the healthcare workforce

During this webinar, sponsored by ShiftKey, attendees will learn:

• The value of the independent worker model and its relevance to healthcare,
• How independent professionals can help combat burnout and improve retention.
• Ways to implement strategic scheduling to attain consistent staffing levels.

Speakers are Regan Parker, chief legal and public affairs officer at ShiftKey, and Brandon Tappan, chief revenue officer at ShiftKey.

But underscoring providers’ ongoing workforce struggles, doing more to recruit and retain at the upper levels hasn’t precluded them from having to make major investments on the front lines.

Nursing home administrator salaries averaged $127,763 in 2023, up 3.6% from $123,324 in 2022. Assistant administrators enjoyed a 5.69% average increase, up to $92,514 from $87,533. Meanwhile, directors of nursing saw their average pay climb 4.67%, up to $108.809 from $103,954 in 2022.

Those figures come from the 2023-2024 HCS Nursing Home Salary & Benefits Report published by Hospital & Healthcare Compensation Service (HCS) in cooperation with LeadingAge and supported by the American Health Care Association. The survey provides compensation data on more than 111,600 employees in 46 management and 54 nonmanagement positions in both nonprofit and for-profit settings.

“The executives … are starting to get a higher percentage after the staff getting the bulk of the increases for probably the last two to three years since COVID. It probably started last year, but it definitely is more pronounced this year,” said Matt Leach, senior consultant with Total Compensation Solutions LLC. “When I talk to the HR folks, when I talk to executives, they almost just throw their hands up and say they’re getting hit from both sides.”

That’s because raises for RNs, LPNs and CNAs remain nearly double the traditional increases of 3% to 5%, even if they are a bit more moderate than 2022 increases. RNs saw an increase of 7% (down from 11.1% in 2022); LPNs enjoyed an increase of 8.9% (down from 9.4% a year earlier); and CNAs saw an increase of 9.7% (down from 11.15% in 2022). 

Need for increases persists

Those numbers were collected in March and published for the first time in late August. But already, providers are facing fresh whiplash, Leach warned.

“Six months ago, it seemed like it was leveling off somewhat, but in the last three months [since mid-summer] we’ve started to see again the need for increases, especially on the staff side,” he said in late September.

“I still think things are calmer than they were a year or two ago, when you couldn’t even get people for interviews,” he added. “But we’ve gotten a lot of calls in the last two months about organizations just not being able to retain talent.”

Workers are constantly asking for more money and expecting mid-year or annual raises of 4%, 5% or even 8% for CNAs, Leach said, adding that meeting such pressures is unsustainable over the long haul.

Staff demands have been compounded by inflationary effects. Many other businesses can keep upping the ante and pass increased staffing costs onto their customers. But in skilled nursing, increases in reimbursement have largely failed to keep up with higher costs in all kinds of categories, making it harder to keep pouring limited resources into salary budget lines.

That only adds to the ongoing workforce crisis, pushing cash-strapped operators closer to the brink. Consulting and accounting firm Clifton
LarsonAllen, using national data, found skilled nursing providers saw their cost of direct care nursing jump by about $4.4 billion, or 12.6%, in 2022, with hourly nursing wages up 10.6%.

“Financial viability and sustainability are a key concern as operators in many states are strategically increasing wages rates far in excess of revenue increases,” said Stephen Taylor, a principal in the firm’s healthcare group. 

“For example, Colorado operators have increased wage rates approximately 27% in the three-year period between 2020 and 2022, while experiencing a median increase in patient revenues of approximately 8%.”

Salary resistance grows, as do bonuses

Leach said some clients are now “taking a harder stand” and trying to limit pay increases while reducing the use of high-cost agency nurses, too.

And that may be accelerating the use of bonuses, which are budgeted as one-time expenses. Leach noted that both higher salaries and bonuses could be due to having to attract new talent as a result of turnover.

Higher compensation in any form is needed to attract younger or recent nursing school graduates as job candidates, added Adam Chambers, founder of Nurse Recruitment Experts. About 30% of his clients are in skilled nursing, and he’s finding it harder than ever to recruit for that setting, in some cases doubling ad spending to net the right RN for a job.

“We’re seeing greater competition because there are fewer qualified nurses compared to the demand, especially in skilled nursing,” Chambers said, noting increases in pay and nurse candidates’ willingness to ask for even more than advertised. “The demand is growing faster because of the aging population, but it tends to attract older nurses. As they retire, they aren’t being replaced quickly from the graduate nurses because they want to work in the hospital.”

While providers must try to offer competitive salaries, that alone isn’t enough to close the deal, Chambers added.

“If they want to earn money as a nurse, then they’ll do travel nursing and hospitals,” he said. “But we find that emphasizing that you’ll have the opportunity to rotate and work with more high-acuity patients [can work]. The best candidates want jobs that challenge the perception that it’s for older nurses and that there isn’t a lot of clinical skill required, which is false.” 

Turnover, vacancies compound 

Leach agreed that higher average pay and bonuses for RNs and higher positions in 2023 likely reflect losses in the leadership ranks. In many places, leaders in top positions stayed in the skilled nursing workforce throughout the early pandemic, even when pulling double duty as the lower ranks thinned.

But burnout caught up with the sector, leaving more mid- and upper-level management positions in skilled nursing facilities vacant, HCS found. The 2023-2024 report is the first to include vacancy rates by position. Providers reported a 14.5% annual vacancy rate for executives, and nearly 21% of all positions were vacant across job roles throughout the year.

Younger nurse leaders and administrators might be more interested in early career bonuses instead of waiting for a larger payout at retirements, Leach said.

HCS found 80% of those providers who offered signing bonuses did so in three or more positions or departments: 48% of participants reported offering sign-on bonuses for RNs, with an average bonus of $4,879; 46% offered bonuses for LPNs, at an average of $3,770; and 40% gave CNAs bonuses, averaging $2,157.

Some providers have taken the bonus strategy to great new heights in recent years, with a New York healthcare system recently offering RNs as much as $35,000 to sign on with its facilities, which include nursing homes and hospitals.

But among staff nurses, Chambers has seen those types of outliers might actually harm recruitment efforts. His recruitment firm conducted its own survey during the pandemic and found that 80% of nurses said they would be less likely to apply for a position offering a high sign-on bonus.

“It seems like common sense to throw money at it,” he said. “But it makes the employer look a little desperate. It’s a red flag on their staffing situation. … And existing staff don’t really like it if someone is getting $35,000 to come in the door and do the same job.”

Instead, he suggests providers try a trick often employed by hospitals to boost early retention efforts. Offer a bonus at signing, after the job has already been offered, to increase employee satisfaction and encourage positive feedback about the organization’s hiring process.

More changes ahead

Hiring and salary strategies will be even more important in coming years, as states and the federal government move toward mandated staffing levels. Leach said pay for some positions may start to bump up even ahead of the federal mandate’s enactment, especially if workers see their value.

Improving retention is a key long-term strategy, and could help save employers money. And the 2023 HCS survey shows that year-over-year turnover declined for the first time since 2020. It noted that turnover rates for RNs dropped to 39% in 2023, approaching the typical rate of 30% to 35% seen prior to 2020; LPN turnover, meanwhile, decreased to 38% in 2023, moving closer to the standard 30% rate seen pre-2020; and CNAs declined to just under 51%.

Reducing those figures to even lower rates will be critical if providers also will have to ramp up hiring for newly created positions needed to meet specific minimums.

“There could be significant implications on labor costs related to the proposed minimum staffing mandate,” said Taylor, whose firm has estimated the annual cost of the federal mandate at $6.8 billion nationally.

“Although there have been improvements in workforce availability in some areas of the country, SNFs in many parts of the nation are still challenged to find the appropriate workforce,” he explained.

“Ultimately, without conduits to building a sustainable supply of direct care nurses, as well as funding to support competitive wages for direct care nursing, the supply and demand could become imbalanced, creating very real [issues with] access to care.”

CHICAGO — The headwinds for skilled nursing operators are significantly more numerous than the potential tailwinds, but there are reasons for provider optimism.

That was the core message from a top national leader Wednesday during his keynote appearance at the annual fall meeting of the National Investment Center for the Seniors Housing and Care (NIC) here.

The demographic surge of elderly patients, greater use of sustainable revenue models, more assumption of risk by providers themselves, and the exploitation of new technologies will boost nursing home operators, said Phil Fogg Jr., president and CEO of Marquis Companies and immediate past board chair of the American Health Care Association.

Those hopes are set against the headwinds of workforce supply, unfunded mandates, aging physical plants, increased ownership scrutiny and politics, to name just a handful, he pointed out. But there are ways to compete, he stressed.

“One of our tailwinds will be our census and our access,” he explained. “I think we’re about three years away from the demographics really impacting long-term care, and then it’s going to really impact long-term care.”

He predicted skilled nursing capacity may continue to decline — 600 facilities have closed since the start of the pandemic, he noted —  which will eventually create incredibly strong demand for services and facilities that remain.

“If you have that capacity issue, you’re going to see the occupancies increase and then you’ll have access [to beds and services] challenges,” he said. ”And if you have access challenges, that could be the one thing I personally see that seems to get the attention of [the Centers for Medicare & Medicaid Services], state governments, of hospitals.

“While we don’t have a lot of tailwinds, in three to five years, you’re going to see that we’re going to increase our negotiating power, probably not just with MA plans but with Medicaid and Medicare,” Fogg added.

Rivals in new roles

Marquis, which has 22 campuses in the Northwest, had to restrict admissions for the first time during the pandemic. Fogg said that was when hospitals began lobbying officials to increase skilled nursing payments so they could clear their acute-care beds faster.

He said skilled care providers should start getting to know their marketplaces and competition better now. 

“You have to be able to come together and work collectively with your providers, even if they’re your competitors, to be able to lift the payment bar,” he counseled. 

He said Marquis has worked collectively with others in its marketplaces because when it comes to competing with Medicare Advantage plans, “it’s all about access. It’s about network adequacy. If you don’t have the ability to influence that, especially if you’re a high-performing network of providers, you’re going to be at risk because they’re going to do whatever they can to you.”

He said that when Marquis first launched its special needs plans, he noticed most other provider types were starting negotiations at 105% of Medicare fee schedules, whereas nursing facilities were accepting only 75% or 85%. 

“I think you have to lift the tidewaters for everyone and compete on the amazing quality and length of stay, value-based payment provisions and not weaken the sustainability of payments by trying to be really competitive,” he said.

“We need to be able to own our own risk and stop having third parties trying to monetize savings off post-acute care episodes or part A and B costs,” he added. “Five years from now, did SNFs get to own that risk or be able to convene that risk or not? Those are the things I look at.”

Technology’s jet stream

Other tailwinds should come from improved use of technology.

“Predictive AI will be a game-changer with population health management,” he said. “I can’t think of a better application of AI than the ability to data mine our EMRs and build intelligence around predicting when somebody’s going to have a change in condition or somebody’s going to be at high risk for a hospital admission.”

He drew parallels to when electronic medication records were first employed and generated “huge savings” through saved nurse labor.

Another tech area to exploit will be remote patient monitoring.

“Monitoring the biometrics of vitals is the next thing in skilled nursing that could be a big deal because it could take a workflow off of staff,” he said. “Then with the interfacing with the EMR you would immediately red-flag any changes in biometrics that could be leading to a change of condition or hospital admission.”

This will help with day-to-day care, as well as the administration of special needs plans, which encourage providers to assume more risk coverage themselves.

‘Getting our butts kicked’

Fogg said he personally didn’t anticipate the devastating impact COVID-19 would have on the long-term care workforce, particularly how hospitals would burn out their nurses and then raid the already-diminished skilled nursing pool.

“There was a certain part of the workforce challenge that would have occurred without COVID, where we just had demographic challenges, especially with licensed nurses and therapists and professionals [in short supply],” he said. “I just don’t think we reacted to the workforce challenges quick enough.”

“[Workforce challenges] could kill us,” Fogg said of the sector overall. “It’s the No. 1 thing that will affect our qualities, that will affect our occupancies. When you have unfunded mandates [such as the administration’s staffing minimum proposed rule] that don’t have any relation to the reimbursement at a state or federal side, it changes the economics in a way that could absolutely kill you.”

He said the non-professional ranks of employees are rebuilding in the workplace but the deficits of nurses, therapists and physicians remain considerable. He said a halving of H-1B visas, some of which go to nurses, hasn’t helped.

“The lack of supply on the immigration side has absolutely damaged and been a major contributing factor to our workforce challenges,” he noted.

“I personally have very little confidence in our education system to increase supply to the levels we need to fill the gap,” he added. “So when I think about this long-term, in the next three to five years, we need to get the foreign healthcare workers into the United States. I think America, we’re losing this battle. At a national level, we’re getting our butts kicked by Canada, and England and Germany.”

He said the declining situation was made clear to him even before COVID hit, when he was on vacation in Croatia, where local talk was about a surplus of healthcare professionals, all English speaking. But he was told the extras typically head to Germany.

That’s why lobbying efforts by AHCA have included a campaign for a new foreign healthcare visa, which would remove dependency on highly competitive H-1B applications and the green card process. A coalition of “every single Medicare provider that works with CMS” is pushing for this, he said. 

“I do think it’s a short-term fix while our education system kind of gets its act together and goes to the capacity we need,” he explained.

No homes on the range?

The urgency is especially acute for rural and semi-rural providers, he said when asked by moderator Steven Monroe if those operators are likely to “just disappear” if staffing pressures don’t subside.

“Yes, I think they will,” Fogg answered. “I think rural healthcare in America is at risk.”

One answer would be creating a “critical access” designation for at-risk rural providers, much like the hospital sector has. That guarantees the government covers operating expenses, up to an allowable level.

“If the government wants to save rural long-term care, it’s going to have to do the same thing — designate rural skilled nursing facilities as critical access and be able to pay the costs,” he said. 

He said he hopes five years from now, progress has been made.

“In an optimal world, we were able to affect foreign healthcare worker visas that brought in 200,000 to 400,000 healthcare professionals a year and the education system filled the depth of need,” he mused of a desired look back. “In an optimal world, we filled up the buildings because there was a lot of increased capacity. We create access issues that increase our negotiating power. And that would create an economic model that’s going to make this profession very sustainable.”

While employees last year clamored for more co-workers to improve their job satisfaction, the most desired change this year was a higher salary, with more than half of survey takers choosing that option. And despite three-quarters (75.1%) reporting being “somewhat satisfied” or “very satisfied” with their current jobs, almost one-quarter (22.6%) said they were “not so well paid,” or “not at all well paid.”

The 2023 survey drew more than 500 responses from directors of nursing and their assistants, and administrators and their assistants. They sent mixed signals about the meaningfulness of their work, their willingness to remain on the job and the changes today’s employers need to adopt to keep them.

Overall, the share of workers “very satisfied” or “somewhat satisfied” with their current job rose about 3% from the 71.9% mark of a year ago.

Cara Silletto, president and chief retention officer of Magnet Culture, said she’s hearing from clients that some staffing stability has been gained over the last six months. But she cautions that any relief from the workforce shortage shouldn’t be viewed as a return to pre-COVID normalcy. In fact, she believes many nursing home leaders see themselves with a new baseline for staffing — one that is leading them to demand better pay even after years of solid increases.

“On this particular question saying more staff will solve my problem, they’re now rolling their eyes and saying, ‘Yeah, yeah, that’d be nice,’” Silletto told McKnight’s Long-Term Care News after reviewing results. “That shrinking staff is why I think they just want higher salaries because they’re going, ‘We’re gonna have to deal with this churn. And so I just need more money because I am never fully staffed. I am never going to get caught up. I am never gonna be not trying to fill tonight’s shift.”

Staffing a ‘smidge’ better

Katie Piperata, a workforce engineer with 15 years’ experience recruiting for skilled nursing, counters that the boost in satisfaction rates and some of the other positive findings from this year’s survey are reflective of the labor crisis “getting a smidge better.” 

She noted the negative “trickle-up” effect of a DON being routinely called to the floor to cover for missing nurses or aides. Administrators then have to step in on some of the DON’s duties, a reality that has hurt satisfaction among both categories of workers in the COVID era.

At National Healthcare Associates, which operates 33 facilities in the Northeast, leaders are trying to combat inflationary pressures with fair salary increases and a culture that prioritizes retention. They’ve seen increased demands for raises and higher asks from new candidates, says Anthony Scarpino, the company’s vice president of talent acquisition. 

“It’s a factor of the rapid inflationary growth of salaries,” he told McKnight’s. “Your salary may fall behind in a single year.”

That could be one explanation for the 52.2% of respondents who said a higher salary would most improve their job satisfaction. That broke down to 51.3% among DONs and 52.8% among administrators.

Just 17.5% of survey respondents said they were “very well paid,” a finding that remained static year-over-year, despite recent raises that exceeded historic averages nationally. Nursing home administrator salaries averaged $127,763, up 3.6% from $123,324 in 2022. Directors of nursing saw their average pay climb 4.67% from $103,954 in 2022 to $108,889 this year, according to the annual HCS Nursing Home Salary & Benefits Report.

Every strategy ‘known to man’

As of this writing, National Healthcare Associates had no openings in its DON or assistant DON ranks, but the perception that wages are stagnant makes it that much tougher to hire when there is a vacancy, Scarpino added. Strategies to retain rather than replace get high priority at NHA.

“I can tell you that we have thought of every bonus incentive, either motivational or retention activity, that is known to man,” Scarpino said. “I think the only time that I’ve seen it more competitive is not necessarily during [the first wave of] COVID, but right after, as we were all trying to open at the same time, we were all trying to return to business.”

Although many providers are focused on competing for staff with agencies, travel nurse firms and other local healthcare entities, Silletto says there is a new foe they may not even take into consideration. That’s a massive increase in healthcare pay transparency, thanks to social media, publicly available surveys and websites, and even new legal requirements for job postings in some states.

“People talk more today about how much money they make than ever before,” she said, also quoting the adage that says, “Comparison is the thief of joy.”

Crazy comparisons

Comparisons between DONs and admins may be driving one significant split identified in the McKnight’s survey: Nearly 23% of DONs said they were “not so well paid” or “not at all well paid,” compared to 14% of administrators.

“It never surprises me that a second-in-command is less thrilled with their pay than the top paid person at any organization,” Silletto added. “A lot of people just think, ‘I should be paid just as much as the next person,’ if they see themselves in a more collaborative role.

“I honestly think there is nothing companies can do — outside of actually paying more — that can overcome this frustration people find,” she said. “When they learn how much money other people make, it is human nature to feel frustrated or jealous or angry.”

Another key finding, however, shows the disconnect between pay satisfaction and meaningful work. For the second year in a row, about 73% of respondents said they found their work “very meaningful.” Among administrators, that share inched up to 75.8%, while 68.7% of DONs reported their work was “very meaningful.”

Workers aren’t bending on flexibility

More nursing home employees also are insisting on flexible scheduling, following years of COVID conditions that have often called on them to work back-to-back shifts and take on overtime they didn’t necessarily want. Survey respondents indicated that not being able to offer flexible work is a major hiring and retention issue in a new economy shaped by the rise of the gig worker.

Overall, 40% of respondents told McKnight’s their workplace had made “some changes, but only for certain employees.” Another 35% said “some flexibility is now available for most employees.” That represents three-fourths (75%) of respondents, but some 13% said their facility or chain had made no effort “at all” to adopt more flexible scheduling.

“While accommodating flexible schedules can sometimes be a challenge for centers, providers need to change the way they have always done things,” said Kendra Nicastro, director of business development for healthcare recruitment firm LeaderStat. “If you are not adapting and developing new ways to attract candidates (flexible schedules, same or next-day pay options, etc.), you will continue to fall behind and recruitment and retention will continue to be a challenge.”

This was the first year that McKnight’s specifically asked whether employers were offering flexible scheduling. But in a separate question about potential changes that would most improve their job satisfaction, slightly more employees chose the option of a more flexible schedule in 2023 than in 2022, rising to 13.7% from 11.4%. Administrators were more likely than nurse leaders to choose that option at 14.6% vs. 12.3%.

Those numbers are likely far lower than if the survey had been offered to all nursing home staff, Silletto said.

“DONs and administrators have the most flexibility in the whole building. They can come and go whenever they want and if their kindergartner kid or grandkid has a two o’clock play, they can leave the building when most of their staff cannot,” she said.

Creativity emerges

That said, building operations are directly impacted by approaches that try to meet the desire for flexibility among other workers. Just under a quarter (24%) of survey respondents said their facility offered self-scheduling tools for employees; 46% had increased part-time opportunities, and 29% offered three- and four-day workweeks.

More than one-third of respondents (161) also entered an answer in “other” options that showed, for the most part, a willingness to explore flexibility. Those included the use of 12-hour shifts; PRN schedules or internal float pool; staggered shifts to accommodate school start times and other personal needs; and shift sharing.

Several respondents also noted in terse terms that their owner or corporate leadership refused to be more flexible with scheduling, or that union contracts prevented facilities from offering some options their peers had found success with.

“Most companies, honestly, haven’t had the bandwidth to explore more flexibility options,” Silletto said. “The way they’ve always scheduled, they know it’s not working, and yet, they don’t know what else to do.”

Middle ground elusive

Piperata said the leadership candidates she works with are “very much” demanding some flexibility, even if it’s just one day a week at home to catch up on all reports, emails and other non-clinical requirements. But she doesn’t see her clients, meaning nursing home HR leaders, budging much.

“When you’re leading the whole building either on the clinical or ops side, it’s the customer who wants to see you, it’s the customer who is wanting that visibility and that representation. So I get where the client is coming from on that,” said Piperata. “But I also get that we’re in this gig worker mentality. People want the flexibility to be able to have a day to get everything done or to work for longer days because staff nurses are able to do Baylor [12-hour weekend] shifts and things that do allow flexibility. So I think we’re just seeing the DON and administrator saying, ‘I want that, too.’ ”

Ted LeNeave, CEO and founder of Accura Healthcare, operates 34 skilled nursing facilities in the Midwest. While he’s hearing more requests for flexible and remote work options, he sees some positions for which that’s just not aligned with the business of doing healthcare. For instance, he recently determined a DON asking to work four days a week in the building wasn’t a “good culture fit.”

“It’s not that kind of job,” he said. “We can have flexibility in other areas, but we can’t have flexibility to not be in the facility if your job is in the facility taking care of those people.”

Scarpino takes a different view. He sees trying to be more amenable to employee desires as a way to avoid costly attrition.

“We don’t see as many people leaving the industry as we see people changing roles for additional pay, a better shift, more flexibility, a better commute,” he said. “I think the whole industry, not just senior living but healthcare in general, is really struggling with this idea of flexibility, particularly with so much attention being given to work from home outside of the industry.”

He’s exploring adding self-scheduling technology, seeing that as one of the best possible solutions. In the meantime, he’s trying to manage candidates — from leaders to brand new CNAs — who ask for special arrangements.

“We just try to be flexible with them as far as we can within the confounds of our operation,” he said. “Whether it’s a 16-hour shift, no weekends, only weekends, days, nights, evenings, those different things. There’s all kinds of different scenarios that we try to piece together to accommodate.”

Seeking solutions

Silletto applauds such flexibility and is encouraging hiring managers to think of their staff more as members of separate pods. One might be PRN and one might be part-timers; and another could be full-time, traditional eight-hour shift workers who never ask for accommodations. The employer can then pay incentives to each pod to ensure round-the-clock coverage.

“I would say an overarching theme — and employers hate to hear this, but it is a current problem — is fewer people in the workforce want to be told where to be when,” she said. “Offering as much flexibility and as many shift options and start and end times as possible helps it fit into their lives. A lot of people are less tolerant today of sacrificing for work.”

For leaders resistant to demands for flexibility, Piperata suggests testing it first in buildings where there might be less risk.

“If you have a 5-star building that’s performing well and the administrator and DON have been there a while, there hasn’t been a lot of turnover, why not allow something like that?” she asked. “I think that maybe they could start to look at it more from a custom standpoint. If your building is doing well, then you can earn this. If these two or three things are met, then this is something that we would work with you on versus just saying, across the board, ‘We’re not doing that.’

Without more change, recruiting nurses who can find the hours they want in hospitals and keeping entry-level employees who have plenty of options in retail or hospitality will continue to be a slog, Piperata said.

Reluctant providers need to think about how their stance positions them in what will only become a more competitive landscape in the coming years, Nicastro added.

“When candidates see flexible scheduling in a job description,” she said, “they can assume that your building is proactively addressing employee requests for work/life balance and working to stem burnout.”

1. Understanding how the easing of the pandemic positively changed rehab care is an important first step.

The challenges of COVID and then-new PDPM rules forced therapists to look at different ways to provide high-quality therapy outside of the usual rehab gym setting, observed Karen Welsh, vice president of clinical and reimbursement excellence for Functional Pathways Rehab.

That was an eye-opening period that will have a lasting, creative impact.

But treatment interventions outside of the patient’s room have returned to near pre-pandemic levels and therapy teams can now resume group activities to allow patients to offer support and suggestions to their rehab peers, said John Pauley, northwest regional vice president for Consonus Healthcare. 

“In a sense, the human connection between therapist and resident has been restored, with changes in masking and isolation policies,” he said. 

2. Therapists can play important roles mitigating the impact of workforce issues.

“As we work together for continued industry stabilization, contract physical therapy companies and skilled nursing providers can efficiently improve patient outcomes and foster a positive and collaborative environment to increase facilities’ marketability for more effective community partnerships and increased census,” said Stephanie Parks, chief development officer for Reliant Rehabilitation. “Work together to develop personalized treatment plans for each patient. Encourage input from the contract physical therapy company and the skilled nursing provider to ensure a comprehensive approach considering the patient’s needs, preferences, and overall care plan.”

Kristin Hoffman, senior customer onboarding specialist for iN2L, suggests scheduling group therapy sessions with activities staff or volunteers if there are caregiver shortages. 

“This can help therapists see a broader range of abilities of their residents’ physical and cognitive abilities without having them on caseload, maybe sparking a need for an eval while still completing their group therapy session,” she said.

3. Develop mechanisms to help staff adapt to  changes that make them better at what they do.

“Facility team members are still adapting to changes from the pandemic,” Pauley said. “It’s important to use clear communication for the reasons behind the changes — and how the changes will be implemented to minimize any concern among staff.”

Added Shelley Horst, director of strategic partnerships for Reliant Rehabilitation: “Addressing staffing shortages in therapy within skilled nursing centers is crucial for providing optimal care to residents.”

4. Many agree that therapists can benefit from understanding how and why workforce shortages are not only affecting the business of long-term care, but also the way they approach their work.

“The key to success with the workforce crisis for therapy and nursing is the ability for the interdisciplinary team to support one another and place the patient’s goals at the center of decision making,” explained Pauley. He noted that therapists are skilled in their ability to assess a patient’s environment, promote needed body positioning and transfers, and provide recommendations that  can reduce caregiver burden. 

5. Though it may seem obvious, experts advise tackling the biggest challenges first.

“Therapists are perfectly positioned to help nursing home caregivers provide the necessary functional tasks by ensuring treatment is delivered during times when it is needed the most — early morning or evening ADLs, all meal times, activities and weekends,” said Welsh. “It’s important for each therapy director to work closely with the leadership team and determine the best way to incorporate therapy into the daily schedule to assist at those times when it’s needed most for patient care.”

Hoffman believes giving patients increased independence by the end of the treatment sessions is another way therapists help reduce caregiver shortages. “The more a patient can do for themselves, the less assistance they will need,” she added.

Physical therapists in long-term care facilities received an average pay increase of 3.7% in 2023, which outpaces increases seen in other healthcare settings serving seniors. 

The lowest hourly rates for long-term care physical therapists were in Bismarck, ND, at $39.26, while the highest rate was in Boston at $51.64 per hour. Los Angeles was a close second for the highest pay at $51.26 per hour, per the report.

The numbers are part of the 17^th annual Hospital and Healthcare Compensation Service Rehabilitation Salary & Benefits Report, which was released Monday and looks at the pay and benefits for therapists in the long-term care sector.

“Long-term care providers have been facing significant workforce challenges for several years, but recent developments suggest that these issues are starting to stabilize,” Rosanne Zabka, director of Reports for the Hospital & Healthcare Compensation Service, said in an email to McKnight’s Long-Term Care News on Tuesday. 

Although the report shows smaller rate increases than in some previous years for LTC therapists, Zabka said a positive indicator is that pay increases are returning to pre-pandemic levels. 

What they earn, base and bonus

The report surveyed 1,455 long-term care facilities and covers data from July 2022 to June 2023. 

The average rate for a director of physical therapy in a long-term care facility is $102,272 with an average bonus of $10,334. Other average rates include: $99,481 for a director of occupational therapy with an average bonus of $9,996; $97,171 for a director of speech language pathology with an average bonus of $10,047. Other findings included: $81,909 for a manager-level PT assistant with an average bonus of $6,781; and $80,048 for a certified OT assistant with an average bonus of $6,641.

All therapy disciplines are expected to see rate hikes from July 2023 to June 2024 ranging from 3.3% for directors of physical therapy, and PT, OT and SLP staff members to 3.38% for OT and SLP directors.

Approximately half of the responding facilities offer assistance for tuition assistance for both hourly and management employees. For hourly employees, 50.1% of respondents offer an average of $4,641; for management employees, the same percentage offer an average of $4,578 for this fringe benefit. One-third of facilities — 33.1% — offer continuing education for hourly employees and 49.7% also make it available to those in management. 

All facilities that responded to the electronic questionnaires offer paid time off for employees, with this benefit ranging from an average of 19.7 days for employees with just one year of work history and up to an average of 29.7 days for employees who have been at the facility for more than 20 years. Most facilities offered holiday pay, with 64.2% providing time-and-a-half and 26.9% offering double-time.

The full report is available from HCS for $325 at www.hhcsinc.com.

A team of researchers from Mass General Brigham evaluated peer-to-peer positive feedback, collected when caring for a dying patient as part of a mandatory mortality review process. It  looked at survey responses from 388 doctors, 212 nurses, 64 advanced practice providers and 1 respiratory therapist at four Mass General Brigham hospitals.

The team found that when it looked at what went right — as opposed to what went wrong — this was a feasible way to boost mutual appreciation among healthcare workers and to provide valuable information to leadership on the hospital’s culture. The positive feedback in medicine, neurology, hospice/palliative care, and surgery focused on taking care of the patients. In emergency medicine, the feedback focused on expertise and composure. 

About 20% of healthcare workers provided positive feedback. The healthcare workers gave the most positive feedback on patient- and family-centered care; provider expertise and composure; and empathy from peers and team collaboration. Most positive feedback acknowledged specific individuals, and nurses provided the most feedback across roles compared to other clinicians.

Some limitations: Researchers didn’t gather outcome data on adverse events, operational efficiency, or clinician well-being or attrition.

“Our study provides rich, qualitative data that highlight the amazing work that our clinicians provide on a daily basis,” Isaac Chua, MD, a palliative care physician at Brigham and Women’s Hospital and lead author, said. “Systematic collection and sharing of positive feedback is a grassroots, low-cost intervention that can help health care leadership understand and improve workplace culture based on the value system of its employees. Receiving and sharing this feedback may also help healthcare workers feel more valued at work, which may protect them against burnout and attrition.”

That’s down from nearly 55% last year, but still far above the 44% recorded a handful of months into the pandemic in 2020 and even farther above the 37% in 2019.

The fact that 47% of administrators and 54% of nursing directors said they were considering leaving their current jobs should still not be viewed as good news, experts told McKnight’s Long-Term Care News.

“That should be an industry wake-up call that half of the people in administration or DONs are continuously considering quitting their job,” even though they find them highly meaningful, warned Cara Silletto, president and chief retention officer of workforce firm Magnet Culture.

Those who stay despite those thoughts may bring their frustrations to the workplace too.

“The reasons they don’t quit their job, even though they think about it or even want to? Some of them are too busy to look for another job. Some of them are making so much money that they don’t want to go get another administrator or DON job because they know it’s going to be the same thing there. And if they switch to any other industry they probably can’t make as much money right out the gate. So the devil you know is better than the devil, you don’t.”

Others are glomming onto changes in the broader healthcare sector and looking for ways to make their jobs work for them, said Katie Piperata, workforce architect at recruiting firm MedBest.

“I think people are kind of building what they want now,” she told McKnight’s. “I have never seen so many people coming to me and asking for interim work, which means, ‘I want to quit my full-time job and just work when I want to on small assignments.’ It fits that gig mentality.”

In Piperata’s experience, fewer people want to leave the industry altogether than during the flood of COVID’s first year. 

And while it appears true that fewer nursing home managers may be leaving over the disease itself, many still say the pandemic and the conditions it led to have made them more likely to exit the profession.

This year, 36% said that COVID has “definitely” or “probably”made them more likely to leave, down from 43% in 2022. COVID’s influence appears most pronounced among administrators, who were less likely to say “no way” to leaving, and more likely to say “definitely” than their DON counterparts.

Overall, 82% of respondents said they thought their contributions at work were valued by colleagues “a great deal” or “a moderate amount.” That measure of satisfaction is on par with 2022 results, which also totaled 82%.

Quitting or dropping out of the race?

One area where numbers slipped was on the advancement side.

Last year, nearly 20% of respondents rated their opportunities for advancement as “excellent.” This year, that share dropped to less than 16%. The share who saw advancement options as “poor,” meanwhile, climbed about 3% to past 18%.

Piperata said that may simply be because there are fewer opportunities for nurse leaders and administrators to advance outside of their buildings, with many regional chain or national operators cutting regional staff to compensate for rising costs.

“Now that we have more staff and staffing is becoming less of an issue, hopefully, corporations that are managing these buildings will start adding back in some of the FTEs that they’ve cut over the last couple years,” she said.

Others may not like the requirements that come with the advancement opportunities they do have.

“A lot of workers today and frontline supervisors, they see what the managers and directors have to go through and they say, ‘You couldn’t pay me enough to do that to work those hours and to put up with all those people and to put up with the corporate office breathing down my neck,’” Silletto said.

Another reason many may still be considering quitting or leaving the profession? The constant workload that remains far above pre-pandemic levels.

Just over 19% of all respondents said they’re “very much so, yes” asked to do too much at work. That sentiment was highest among nurse leaders at 22%.

Another 36.5% said they were “generally” asked to do too much, which is actually a decline from the 2022 rate of 40%.

Workloads continue to crush

Overall, nurse leaders this year were 10 percentage points more likely to report being some level of overworked than their peers in administration.

That kind of sustained frustration must reach the ears of owners and operators who make financial decisions around staffing levels, Silletto said. Thinking that 60-hour workweeks will continue to be acceptable to a generation of workers, even building leaders, who value work differently, will only lead to more long-term problems, she added.

“I would venture to say that the ‘quiet quitting’ phenomenon that happened last year, with directors of different departments saying, ‘enough’ after having been through the pandemic, they said, ‘I am going to do my job, but I am not gonna kill myself anymore here. I’m just not gonna do that,’” Silletto said. “A lot of people finally realized that the workloads were unmanageable and unsustainable.”

This is the third article in a four-part series revealing the findings of the 2023 McKnight’s Mood of the Market survey. The first on job satisfaction appeared Aug. 31, followed by the second on flexibility demands on Sept. 6. Check back next week for the final installment on wage and inflation pressures.

Overall, however, job satisfaction rose noticeably over the last year. And an overwhelming share of respondents reported they still found their work meaningful, even if fewer believed their efforts were fully appreciated.

Employees last year clamored for more co-workers to improve their job satisfaction. But the most desired change this year was a higher salary, with more than half of survey takers choosing that option. And despite three-quarters (75.1%) reporting being “somewhat satisfied” or “very satisfied” with their current jobs, almost one-quarter (22.6%) said they were “not so well paid” or “not at all well paid.”

The 2023 survey drew more than 500 responses from directors of nursing, assistant directors of nursing, and administrators and their assistants. They sent mixed signals about the meaningfulness of their work, their willingness to remain on the job and the changes today’s employers need to adopt to keep them.

The share of workers “very satisfied” or “somewhat satisfied” with their current job rose about 4%, up from 70.9% in 2022.

Cara Silletto, president and chief retention officer of Magnet Culture, said she’s hearing from clients that some staffing stability has been gained over the last six months. But she cautions that any relief from the workforce shortage shouldn’t be viewed as a return to pre-COVID normalcy. In fact, she believes many nursing home leaders see themselves with a new, lower staffing baseline — one that is leading them to demand better pay even after years of solid increases.

“On this particular question saying more staff will solve my problem, they’re now rolling their eyes and saying, ‘Yeah, yeah, that’d be nice,’” Silletto told McKnight’s Long-Term Care News after reviewing results. “They just want higher salaries because they’re thinking, ‘We’re gonna have to deal with this churn. And so I just need more money because I am never fully staffed. I am never going to get caught up. I am never gonna be not trying to fill tonight’s shift.”

Staffing a ‘smidge’ better

Katie Piperata, a workforce engineer with 15 years experience recruiting for skilled nursing, counters that the boost in satisfaction rates and some of the other positive findings from this year’s survey are reflective of the labor crisis “getting a smidge better.” 

She noted the negative “trickle-up” effect of a DON being routinely called to the floor to cover for missing nurses or aides. Administrators then have to step in on some of the DON’s duties, a reality that has hurt satisfaction among both categories of workers in the COVID era.

These workers have also seen less external support as inflation cut into margins and led to regional staffing changes at many nursing home chains.

“Now that we have more staff and staffing is becoming less of an issue, hopefully, corporations that are managing these buildings will start adding back in some of the FTEs that they’ve cut over the last couple years,” added Piperata, with Tampa-based MedBest. “A lot of what I saw cut was more on the regional side, not the administrator or the DONs, but the people that they report to. I’m hoping that some of that support starts coming back because that’s how you mentor your administrators and DONs. You have to have enough people above helping and grooming and growing them.”

Survey finds satisfaction on the line

At National Health Care Associates, which operates 33 facilities in the Northeast, leaders are trying to combat inflationary pressures with fair salary increases and a culture that prioritizes retention. They’ve seen increased demands for raises and higher asks from new candidates, says Anthony Scarpino, the company’s vice president of talent acquisition. 

“It’s a factor of the rapid inflationary growth of salaries,” he told McKnight’s. “Your salary may fall behind in a single year.”

That could be one explanation for the 52.2% of respondents who said a higher salary would most improve their job satisfaction. That share was 51.3% among DONs and 52.8% among administrators.

Just 17.5% of all McKnight’s survey respondents said they were “very well paid,” a finding that remained flat from year-to-year, despite recent raises that exceeded historic averages nationally. Among administrators, that figure was 18.5% and it was just 16.1% among nurse leaders.

Nursing home administrator salaries averaged $127,763, up 3.6% from $123,324 in 2022, while directors of nursing saw their average pay climb 4.67% from $103,954 in 2022 to $108,889, according to the annual HCS Nursing Home Salary & Benefits Report.

National currently has no openings in its DON or assistant DON ranks, but the perception that wages are stagnant makes it that much tougher to hire when there is a vacancy, Scarpino added. Strategies to retain rather than replace get high priority at the company.

“I can tell you that we have thought of every bonus incentive, either motivational or retention activity, that is known to man. Depending on the location that you work at, there’s a different combination that may be in place. We’ve tried things in one building that didn’t work and work really well in another building,” Scarpino said. “I think the only time that I’ve seen it more competitive is not necessarily during [the first wave of] COVID, but right after, as we were all trying to open at the same time, we were all trying to return to business.”

Comparison or collaboration?

Although many providers are focused on competing for staff with agencies, travel nurse firms and other local healthcare entities, Silletto says there is a new foe they may not even take into consideration. That’s a massive increase in healthcare pay transparency thanks to social media, publicly available surveys and websites and even new legal requirements for job postings in some states.

“People talk more today about how much money they make than ever before,” she said, also quoting the adage that says “Comparison is the thief of joy.”

And comparisons between DONs and admins may be driving one split identified in the McKnight’s survey: Nearly 23% of DONs said they were “not so well paid” or “not at all well paid,” compared to 14.3% of administrators.

“It never surprises me that a second-in-command is less thrilled with their pay than the top paid person at any organization,” Silletto observed. “A lot of people just think, ‘I should be paid just as much as the next person,’ if they see themselves in a more collaborative role.”

“I honestly think there is nothing companies can do — outside of actually paying more — that can overcome this frustration people find,” she said. “When they learn how much money other people make, it is human nature to feel frustrated or jealous or angry.”

Years of unrelenting stress may also be undercutting the teamwork that so many facilities count on to keep operations stable. The share of respondents saying they feel their contributions are valued by their colleagues “a great deal” fell more than 4%, from 45.7% last year to 41.5% this year.

That doesn’t necessarily equate to dislike of the job, though. For the second year in a row, about 73% of respondents said they found their work “very meaningful.” Among DONs, that share inched up to 75.8%, while 68.7% of DONs reported their work was “very meaningful.”

This is the first in a four-part series revealing the finding of the 2023 McKnight’s Mood of the Market survey. See additional installments at www.mcknights.com/tag/mood-of-the-market/.