nursing home working requirements

Nursing Home Basics: Who Qualifies, Who Pays, and Other Helpful Facts

Why it matters.

Understanding how nursing homes work can be confusing because standards for eligibility, insurance coverage, etc. vary from state to state in the US.

In this second article in our series on nursing homes ( read Part I here ), we answer some commonly asked questions about nursing home structures and functions.

Who Is Eligible to Enter a Nursing Home?

People qualify for nursing home/facility level of care (NFLOC) if they are unable to live alone safely in the community. There is no federal definition of NFLOC and the exact rules governing level of care vary from state to state. Despite this lack of consistency, the following four areas are commonly considered when a state determines a person’s level of care need: physical functional ability; health issues/medical needs; cognitive impairment; and behavioral issues. In many states, there has been significant rebalancing toward home and community-based services and away from nursing home care. Check state websites for updated information on specific eligibility requirements.

Who Pays for Nursing Home Care?

Medicare is the federal health insurance program for people in the US who are 65 or older, some younger people with disabilities, people with End-Stage Renal Disease. A common misconception is that Medicare will pay for all nursing home costs. This is not true.

Post-acute care (PAC) or skilled nursing facility (SNF) care is usually covered by Medicare or private insurance up to 100 days (100 percent for 20 days and then 80 percent for 80 days based on certain criteria). Long-term care (meals, room and board, and basic health services) is often paid for privately until funds are spent down. A “ spend down ” is how someone with Medicare may qualify for Medicaid — a joint federal and state program that provides health coverage to some people with limited income and resources — even if their income is higher than a state's Medicaid limit. Under a spend down, a state lets the person subtract their non-covered medical expenses and cost sharing (like Medicare premiums and deductibles) from their available income. Each state’s Medicaid program covers approximately 70 percent of nursing home care.  Long-term care insurance can also pay for nursing home care, but relatively few people have it.

The average cost of a nursing home is over $90,000 per year but this varies state to state. Multiple organizations provide information about nursing home costs and Medicaid daily rates online, including the  American Council on Aging .

Who Oversees and Regulates Nursing Home Quality and Safety?

The Centers for Medicare and Medicaid Services (CMS) oversees nursing home quality and safety at the federal level. Several divisions have regulations that pertain to nursing homes. 

The CMS Division of Nursing Homes develops and oversees most nursing home regulations. CMS delegates nursing home surveys and inspections to a designated organization in each state, usually the State Survey Agency (SSA). SSAs conduct annual, recertification, and complaint surveys and assess compliance with regulations. There is also a Special Focus Facility program for a small number of low-performing nursing homes that receive more intensive oversight and guidance on quality improvement in each state.

How Do We Measure Nursing Home Quality?

Because definitions of quality may vary, there are different methods used by federal, state, or private organizations to collect and analyze quality data. Here are a few examples:

• Minimum Data Set (MDS) is a standardized assessment tool required by CMS that measures health status in nursing home residents. All nursing homes that accept Medicare or Medicaid must submit the MDS regularly for each resident to receive payment.
• National Healthcare Safety Network is an electronic system for infection reporting, including COVID and other data that goes to CDC.
• CMS Five Star Quality Rating System gathers information from inspections (surveys), quality measures, and staffing from each nursing home and makes this information publicly available on the CMS website.
• Medicare’s Care Compare   allows users to locate and compare data from nursing homes.

What are Quality Innovation Networks-Quality Improvement Organizations (QIN-QIOs)?

QIN-QIOs focus on working with nursing homes, states, and regions to improve quality of life and quality of care across settings, including nursing homes. QIN-QIOs have their own separate line item in the US federal budget to support the national program which covers  all 50 states and US territories . QIN-QIOs are not part of state survey agencies or the survey process. Their focus is on quality improvement, support, education, and training, which are often provided free or at very low cost.

Who Works in Nursing Homes?

Women make up most of the nursing home workforce, particularly direct care workers such as certified nursing assistants (CNAs). ( Almost 90 percent of nursing assistants are female). Many are single parents.  People of color comprise most of the US nursing assistant workforce.

Most nursing assistants are low-income wage earners. Many live at or near the federal poverty level and almost half receive some type of public assistance. Nursing homes typically pay CNAs the minimum wage, but this is not necessarily a livable wage depending on where they live. For this reason, CNAs often work in multiple settings and have multiple jobs. For many CNAs, English is not their first language, and they may have limited English proficiency. Many are immigrants.

What Are Some Challenges Faced by the Nursing Home Workforce?

There are many issues facing nursing home CNAs today and some new opportunities. The National Association of Health Care Assistants (NAHCA) conducted a survey of 1,420 CNAs in July 2023. When asked about their jobs, many CNAs reported that low wages and benefits would be the primary reasons they intend to seek another type of employment. They also cited unstable or inadequate hours, lack of supervisor’s/manager’s support, lack of career advancement or professional development, and feeling under-valued.

High rates of turnover (in some cases over 100 percent in a year) and the need for stronger, stable leadership are important reasons to better support CNAs and other direct care workers. Creating and testing standardized career ladders or lattices and providing more training and education on topics of interest to CNAs represent opportunities to promote better retention and reduce turnover. Another way to respond to CNA concerns is by becoming an  Age-Friendly Health Systems Nursing Home .

Alice Bonner, PhD, RN, is IHI’s Senior Advisor for Aging. Amanda Meier, BSW, MA, is IHI’s Project Manager, Age-Friendly Health Systems. If you have any questions or ideas about nursing homes or related policy issues, please feel free to reach out to Alice Bonner ( [email protected] ) or Amanda Meier ( [email protected] ).

You may also be interested in:

The Basics We (and Policymakers) Should Know about Nursing Homes

Centering What Matters: The Core of Age-Friendly Care

Related Insights

Find answers to many of your Social Security questions in our new YouTube video series.

AARP daily Crossword Puzzle

Hotels with AARP discounts

Life Insurance

AARP Dental Insurance Plans

AARP MEMBERSHIP 

AARP Membership — $12 for your first year when you sign up for Automatic Renewal

Get instant access to members-only products, hundreds of discounts, a free second membership, and a subscription to AARP the Magazine. Find how much you can save in a year with a membership.  Learn more.

• right_container

Work & Jobs

Social Security

• AARP en Español

• Membership & Benefits
• Members Edition

AARP Rewards

• AARP Rewards %{points}%

Conditions & Treatments

Drugs & Supplements

Health Care & Coverage

Health Benefits

AARP Hearing Center

Advice on Tinnitus and Hearing Loss

Get Happier

Creating Social Connections

Brain Health Resources

Tools and Explainers on Brain Health

Your Health

8 Major Health Risks for People 50+

Scams & Fraud

Personal Finance

Money Benefits

View and Report Scams in Your Area

AARP Foundation Tax-Aide

Free Tax Preparation Assistance

AARP Money Map

Get Your Finances Back on Track

How to Protect What You Collect

Small Business

Age Discrimination

Flexible Work

Freelance Jobs You Can Do From Home

AARP Skills Builder

Online Courses to Boost Your Career

31 Great Ways to Boost Your Career

ON-DEMAND WEBINARS

Tips to Enhance Your Job Search

Get More out of Your Benefits

When to Start Taking Social Security

10 Top Social Security FAQs

Social Security Benefits Calculator

Medicare Made Easy

Original vs. Medicare Advantage

Enrollment Guide

Step-by-Step Tool for First-Timers

Prescription Drugs

9 Biggest Changes Under New Rx Law

Medicare FAQs

Quick Answers to Your Top Questions

Care at Home

Financial & Legal

Life Balance

LONG-TERM CARE

​Understanding Basics of LTC Insurance​

State Guides

Assistance and Services in Your Area

Prepare to Care Guides

How to Develop a Caregiving Plan

End of Life

How to Cope With Grief, Loss

Recently Played

Word & Trivia

Atari® & Retro

Members Only

Staying Sharp

Mobile Apps

More About Games

Right Again! Trivia

Right Again! Trivia – Sports

Atari® Video Games

Throwback Thursday Crossword

Travel Tips

Vacation Ideas

Destinations

Travel Benefits

Beach Vacation Ideas

Fun Beach Vacations

Road Trips For Every Personality

Passport Access

Passports Can Be Renewed Online

AARP National Park Guide

Black Canyon of the Gunnison

Entertainment & Style

Family & Relationships

Personal Tech

Home & Living

Celebrities

Beauty & Style

Movies for Grownups

Summer Movie Preview

Jon Bon Jovi’s Long Journey Back

Looking Back

50 World Changers Turning 50

Sex & Dating

7 Dating Dos and 7 Don'ts

Friends & Family

Veterinarians May Use AI to Treat Pets

Home Technology

Caregiver’s Guide to Smart Home Tech

Virtual Community Center

Join Free Tech Help Events

Creative Ways to Store Your Pets Gear

Meals to Make in the Microwave

Wearing Shoes Inside: Pros vs. Cons

Driver Safety

Maintenance & Safety

Trends & Technology

AARP Smart Guide

How to Clean Your Car

We Need To Talk

Assess Your Loved One's Driving Skills

AARP Smart Driver Course

Building Resilience in Difficult Times

Tips for Finding Your Calm

Weight Loss After 50 Challenge

Cautionary Tales of Today's Biggest Scams

7 Top Podcasts for Armchair Travelers

Jean Chatzky: ‘Closing the Savings Gap’

Quick Digest of Today's Top News

AARP Top Tips for Navigating Life

Get Moving With Our Workout Series

You are now leaving AARP.org and going to a website that is not operated by AARP. A different privacy policy and terms of service will apply.

Federal Nursing Home Staffing Standards to Increase Care Hours for Residents

A new rule also requires registered nurses to be on site around the clock.

Maura Kelly Lannan,

The Biden administration has set minimum staffing levels for nursing homes for the first time under a rule announced Monday, which establishes comprehensive staffing requirements and requires facilities to have a registered nurse on site at all times. 

The announcement, made by Vice President Kamala Harris, comes in response to concerns about the adequacy of care in nursing homes in general as well as about 188,000 nursing home resident deaths since the COVID-19 pandemic. The pandemic also exacerbated long-standing staffing shortages in nursing homes.

Get instant access to members-only products and hundreds of discounts, a free second membership, and a subscription to AARP the Magazine. Find out how much you could save in a year with a membership.  Learn more.

The new rule, which was proposed in September by the Centers for Medicare & Medicaid Services (CMS), requires that nursing homes that receive funding through Medicare  and Medicaid provide the staffing equivalent of at least 3.48 hours of nursing care per resident, per day. That includes 0.55 hours of care from a registered nurse and 2.45 hours of care from a nurse aide each day, according to a White House fact sheet.

A registered nurse also must be on site 24 hours a day, seven days a week, to provide skilled nursing care at the facilities, which are home to about 1.2 million people nationwide, according to the new rule.

Requirements for additional hours of nursing care will prevent workers from being “stretched too thin” and bar nursing homes from understaffing sites, the White House noted.

“When facilities are understaffed, residents may go without basic necessities like baths, trips to the bathroom, and meals – and it is less safe when residents have a medical emergency,” the White House fact sheet noted.

AARP NEWSLETTERS

%{ newsLetterPromoText  }%

%{ description }%

Privacy Policy

ARTICLE CONTINUES AFTER ADVERTISEMENT

Minimum staffing requirements will “help protect the basic rights of residents to live in dignity” and is long overdue, especially for facilities that are funded through taxpayer dollars, Nancy LeaMond, AARP’s executive vice president and chief advocacy and engagement officer, said in a statement.

“Far too many residents and families have experienced tragic consequences because of poorly staffed facilities,” LeaMond said in the statement, adding that “ensuring nursing homes are adequately staffed will improve the quality of care residents receive and can give family caregivers peace of mind, knowing their loved ones are living with the quality of life they deserve.”

AARP® Dental Insurance Plan administered by Delta Dental Insurance Company

Dental insurance plans for members and their families

More staff likely needed

Many nursing home facilities will need to hire staff to meet the new requirements, the White House said, noting that a facility with 100 residents would need two or three registered nurses and at least 10 or 11 nurse aides, as well as two additional nurse staff, who could be registered nurses, licensed professional nurses or nurse aides, per shift to meet the new standards.

President Joe Biden pushed for minimum staffing levels in nursing homes in his 2022 State of the Union address. The COVID-19 pandemic highlighted long-term problems in nursing homes, including the decline in staffing, issues regarding infection control deficiencies and inadequate oversight.

Current law requires facilities to have licensed nursing services around the clock that are “sufficient” to “maintain the highest practicable physical, mental, and psychosocial well-being of each resident.”

Nursing home industry groups said the new rule and requirements will be hard to meet because of staff shortages.

The American Health Care Association (AHCA), a national lobbying group representing more than 14,000 long-term care providers, issued a statement calling the rule “an unreasonable standard.” The group said the new staff requirements could lead to nursing home shutdowns and the displacement of residents.

LEARN MORE ABOUT AARP MEMBERSHIP.

Get instant access to members-only products and hundreds of discounts, a free second membership, and a subscription to AARP the Magazine.

“Issuing a final rule that demands hundreds of thousands of additional caregivers when there’s a nationwide shortfall of nurses just creates an impossible task for providers,” the AHCA said in a statement. “This unfunded mandate doesn’t magically solve the nursing crisis.”

The new staffing requirements will be introduced in phases, with rural communities given a longer time to comply, according to the White House. Limited, temporary exemptions also will be available for the around-the-clock nurse requirement and the staffing standards in areas where there are workforce shortages and a good faith effort to hire.

The announcement Monday comes one month after a federal government report highlighted lessons learned from the pandemic for nursing homes and found that CMS should do more to prevent staffing shortages in nursing homes and strengthen infection controls to better protect residents after the COVID-19 pandemic.

Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy, a legal nonprofit working to advance access to health care coverage, said the new rule doesn't end the discussion of staffing levels. Each facility must annually conduct an assessment to determine the nursing needs of its residents and to ensure it has enough staff with the skills to meet those needs.

"Properly implemented and enforced, the facility assessment process will require many facilities to implement higher staffing levels than the minimums announced today," he said in a statement.

Maura Kelly Lannan is a writer, editor and producer for AARP who covers federal and state policy. She has worked as a reporter for the Associated Press, the Chicago Tribune and the Waterbury, Connecticut, Republican-American . She also has written for Bloomberg Government, The Boston Globe and other publications.

Unlock Access to AARP Members Edition

Already a Member? Login

More From AARP

Biden Administration Proposes First-Ever Nursing Home Staffing Standards

75 percent of facilities would need to increase staffing levels, government estimates

Nursing Homes Reach 2 Million COVID-19 Resident Cases

AARP analysis finds deaths rose in December, January

Is a Wave of ‘Transfer Trauma’ Coming?

20 patients in a rural facility were told to move out. More than half are now dead.

Recommended for You

AARP Value & Member Benefits

Learn, earn and redeem points for rewards with our free loyalty program

The National Hearing Test

Members can take a free hearing test by phone

AARP® Staying Sharp®

Activities, recipes, challenges and more with full access to AARP Staying Sharp®

SAVE MONEY WITH THESE LIMITED-TIME OFFERS

We use cookies on our website to support technical features that enhance your user experience, and to help us improve our website. By continuing to use this website, you accept our privacy policy .

• Student Login
• No-Cost Professional Certificates
• Call Us: 888-549-6755
• 888-559-6763
• Search site Search our site Search Now Close
• Request Info

Skip to Content (Press Enter)

The Beginner's Guide to Working in a Nursing Home

By Kristina Ericksen on 02/22/2016

Nursing homes are becoming the new normal.

By 2050, the U.S. 65+ population will double from what it was in 2012 to a staggering 83.7 million. And while many families would like to care for their aging relatives, they’re not always able to do so themselves. That’s where nursing homes come into play.

Looking forward, the aging population combined with the national nursing shortage will create an even greater demand for healthcare professionals. This means employment in a nursing home could very well be in your future.

You love caring for others, but are you really cut out for working in a nursing home? Is it that different from other nursing settings?

We spoke to seasoned nurses to see what they liked best about long-term care in a nursing home – and their answers may surprise you! Here’s what they have to say.

Get Your Nursing School Questions Answered at a Nursing Information Session

Reserve Your Spot

What is it like working in a nursing home?

Working in a nursing home is special in that you’ll be a member of the care team collectively taking care of your residents. And because these are long-term care residents, you’ll get to know them and their conditions much better than in other types of nursing positions. Everyone works together to provide the best care for the residents.

You’ll play an important role in an interdisciplinary team, including physical therapy, occupational therapy, speech therapy, social work, case management and more. Together you’ll work on forming beneficial care plans for your patients, explains Rebecca Lee , RN.

And if you’re worried that nursing homes aren’t active and lively enough for you, think again.

“A few of our residents were bat mitzvah’d in their 80s and 90s,” shares RN Josie Vega. “Some have dementia, but revert to teenage girls and sing along when an Elvis impersonator visits. When the pet therapy dog arrives, residents talk about the puppies they once had.”

Many residents are still very proud of the lives they lived, the families they raised and the things they accomplished personally and professionally. You get to honor their legacy and contributions to society when you’re at the bedside, she adds.

What skills are needed to work in a nursing home?

Nurses in nursing homes need a different skill set than nurses in a hospital or clinic. These specialized skills allow them to concentrate their care to the needs of their residents. Hospice, rehabilitation and therapy differentiate nursing home nurses from those in more traditional settings. And they also have more involvement in the case management of their residents.

“It’s important to deliver quality care with compassion, dignity and respect,” Vega says. “A resident’s inability to see, hear or talk makes them particularly vulnerable so it’s important to notice nonverbal communication.”

But what are the most important skills you’ll need to succeed in these positions? We used real-time job analysis software to examine nearly 300,000 nurse job postings from nursing homes over the past year.* The data helped us identify the top 10 skills needed in nursing home positions.

Here is what we found:

• Patient care
• Home health
• Treatment planning
• Case management
• Patient/family education
• Medical administration
• Advanced cardiac life support (ACLS)
• Patient evaluation

What are the advantages of working in a nursing home?

As with any occupation, there are various pros and cons that come with the job. Here’s what our nurses noted as some of the perks of being a nursing home nurse:

1. You’ll get to know your patients better

“Get ready to become attached to your residents and their families,” Vega says. “They become a part of who you are and there is a special bond formed in long-term care.”

Working in a nursing home offers the opportunity to foster relationships with long-term residents more so than would be possible in an outpatient or a more traditional nursing setting.

2. You’ll sharpen your pharmacology skills

As a registered nurse, you hand out a lot of medications in nursing homes. Your pharmacology skills will improve, according to Lee.

3. You’ll work as a team

Members of the care team—including social work, therapeutic recreation, music therapy, dietary and even housekeeping—all work together for the good of the patients. This kind of camaraderie is unique and makes stressful days more enjoyable.

“The nurses are just one part of the total care package. I like that,” Vega says.

4. You’ll experience variety

You see all types of diagnoses because nursing homes are basically a generalized internal medicine unit, says Lee. This type of diversity means you’ll rarely have a boring day on the job.

5. It’s less physically demanding

Though you will be on your feet much of the day, working in a nursing home is typically less physically demanding than other options for nursing careers, according to Lee.

What are the disadvantages of working in a nursing home?

There are two sides to every coin, With the various benefits also comes a few drawbacks to working in a nursing home. Here’s what the nurses have to say:

1. You'll get attached to patients

There is a downside to establishing close relationships with your residents. You’ll inevitably develop a favorite resident or two because it’s so easy to get attached, according to Vega. Whenever a resident’s health declines, it can be heartbreaking, she adds.

2. There is a stigma about nursing homes in general

“I dislike that nursing homes get such a bad rap. People have so many negative perceptions of life at a nursing home,” Vega says.

You may work in the most wonderful nursing home in the world, but there will still be some that see it otherwise. Overcoming these misconceptions is something that you’ll likely learn to deal with on a regular basis.

3. Your skills are more concentrated

“You don't gain as much acute medical knowledge because you're working in a low-intensity environment,” Lee says.

She points out that nurses in nursing homes don’t get to practice EKGs, responding to medical codes, starting IVs, drawing cultures and blood tests, calculating medication drips or starting A-lines. So if you’re looking for an environment to help you hone those skills, a nursing home may not be your top choice.

Now you know…

Working in a nursing home is not for everyone. It takes a special person to care for the most vulnerable patients in their final years. But with the aging population, elderly patients will need your care now more than ever.

RELATED ARTICLES:

• Acute Care vs. Ambulatory Care: Which Nursing Environment is Right for You?
• Teamwork in Nursing: How to be a Key Contributor in Your Unit
• Best Day on the Job: 4 Nursing Stories that Prove it's All Worth it
• Nocturnal Nurses Uncover the Secrets of Working the Night Shift

*Source: BurningGlass.com (Analysis of 296,316 nursing home nurse job postings, Feb. 1, 2015 – Jan. 31, 2016) AUTHOR'S NOTE: This article was originally published in February 2014. It has since been updated to include information relevant to 2016.

• Share on Facebook
• Share on Twitter
• Share on Pinterest
• Share on LinkedIn

Request More Information

Talk with an admissions advisor today.

Fill out the form to receive information about:

• Program Details and Applying for Classes
• Financial Aid (for those who qualify)
• Customized Support Services
• Detailed Program Plans

There are some errors in the form. Please correct the errors and submit again.

Please enter your first name.

Please enter your last name.

There is an error in email. Make sure your answer has:

• An "@" symbol
• A suffix such as ".com", ".edu", etc.

There is an error in phone number. Make sure your answer has:

• 10 digits with no dashes or spaces
• No country code (e.g. "1" for USA)

There is an error in ZIP code. Make sure your answer has only 5 digits.

Please choose a School of study.

Please choose a program.

Please choose a degree.

The program you have selected is not available in your ZIP code. Please select another program or contact an Admissions Advisor (877.530.9600) for help.

The program you have selected requires a nursing license. Please select another program or contact an Admissions Advisor (877.530.9600) for help.

Rasmussen University is not enrolling students in your state at this time.

By selecting "Submit," I authorize Rasmussen University to contact me by email, phone or text message at the number provided. There is no obligation to enroll. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

About the author

Kristina Ericksen

Kristina is a Digital Writer at Collegis Education where she creates informative content on behalf of Rasmussen University. She is passionate about the power of education and enjoys connecting students to bright futures

Posted in General Nursing

• nursing careers

Related Content

Brianna Flavin | 05.07.2024

Brianna Flavin | 03.19.2024

Robbie Gould | 11.14.2023

Noelle Hartt | 11.09.2023

This piece of ad content was created by Rasmussen University to support its educational programs. Rasmussen University may not prepare students for all positions featured within this content. Please visit www.rasmussen.edu/degrees for a list of programs offered. External links provided on rasmussen.edu are for reference only. Rasmussen University does not guarantee, approve, control, or specifically endorse the information or products available on websites linked to, and is not endorsed by website owners, authors and/or organizations referenced. Rasmussen University is accredited by the Higher Learning Commission, an institutional accreditation agency recognized by the U.S. Department of Education.

Pardon Our Interruption

As you were browsing something about your browser made us think you were a bot. There are a few reasons this might happen:

• You've disabled JavaScript in your web browser.
• You're a power user moving through this website with super-human speed.
• You've disabled cookies in your web browser.
• A third-party browser plugin, such as Ghostery or NoScript, is preventing JavaScript from running. Additional information is available in this support article .

To regain access, please make sure that cookies and JavaScript are enabled before reloading the page.

Brief Update on State and Federal Long-Term Care Staffing Requirements

Long-term care workforce shortages exist in in all states, exacerbated by an  increasingly older U.S. population  with complex care needs and  high turnover rates that have not recovered  since the COVID-19 pandemic. Within this space, nursing facilities are facing unique pressure through proposed federal rules that may increase demand for long-term care professionals.  

Since 1996, research has identified  nursing staffing levels as a critical factor in quality of care in nursing facilities.  A 2001 study by the Centers for Medicare & Medicaid Services  (CMS) recommended a total of 4.1 hours of nursing care per resident per day (HPRD), including:  

• 0.75 hours provided by a registered nurse (RN). 
• 0.55 hours provided by a licensed professional nurse (LPN) or licensed vocational nurse (LVN). 
• 2.8 - 3.0 hours provided by a certified nursing assistant (CNA).  

The federal government historically has not set HPRD or staffing ratio requirements. States may set minimum staffing requirements, and most fall short of recommended staffing levels. 

Proposed Federal Staffing Requirements

Federal law currently requires  nursing homes that receive reimbursement from Medicaid or Medicare to provide 24-hour licensed nursing services, which are “sufficient to meet the nursing needs of [their residents].”  

In September 2023, CMS issued a proposed rule  that would establish the first minimum staffing levels for nursing facilities. The rule would require 24/7 RN staffing and set HPRD requirements for RNs and CNAs, but does not include requirements for LPNs or LVNs. All facilities would have to complete an individual needs assessment within 60 days following publication of the final rule. Urban and suburban facilities would have three years following publication to implement staffing requirements; rural facilities would have up to five years. The proposed rule would permit a hardship exemption if a facility can document the unavailability of a local nursing workforce and good faith efforts to hire and retain staff. 

According to KFF , over 80% of nursing facilities would need to hire nursing staff to meet the required number of hours for registered nurses and nurse aides if the rule were to pass. In more than half of states, less than one-quarter of nursing facilities would meet the proposed staffing requirements.  

Existing State Staffing Requirements

In addition to federal requirements, states may set additional nursing facility requirements through “sufficient staffing” standards, staffing ratios or HPRD requirements, as shown in the map below.

State Staffing Requirements for Nursing Facilities

Note: NCSL is in the process of obtaining the statutes from territories and will update when they are available.

States generally include language aligning with federal requirements that an RN must be on-duty for eight consecutive hours per day, seven days per week. States may distinguish staffing ratios or HPRD requirements by shift ( Arkansas ), level of care ( Massachusetts ) or the number of residents ( Idaho ). 

At least 16 states include unspecified sufficient staffing requirements, and at least 34 states and the District of Columbia define a staffing ratio or HPRD requirement in statute.  Oregon  defines minimum staffing ratios for nursing facilities based on day, evening and night shifts, but notes that these “numbers represent a minimum staffing requirement, not sufficient staffing.” States may include direct bedside care provided by the director of nursing or charge nurse in staffing requirements ( New Mexico ), or they may exclude these positions from staffing ratio and HPRD requirements ( Kansas ).  

State Actions to Bolster the Long-Term Care Workforce 

States are turning to recruitment and retention strategies to bolster long-term care staffing in years to come. Understanding the magnitude and unique challenges of the long-term care workforce is often an important step for states. Several have required statewide studies on the topic, including  Colorado ,  Florida ,  Maryland  and  Minnesota .  

Many states collaborate with local education institutions to  establish career pathway programs  into and throughout long-term care occupations.  Following a study of health professions in 2018 , Indiana’s largest community college,  Ivy Tech , leveraged data to create a CNA bridge program toward a “Certificate in Pre-Nursing Studies.” This is considered a pathway into the Practical Nursing and Associate of Science in Nursing programs.  Washington  launched the  Long-Term Care Project  in July 2022, creating an apprenticeship with local community and technical colleges to provide on-the-job training for CNAs and home care aides to become LPNs.  

Direct care jobs tend to pay wages near or below the poverty threshold.  Women of color comprise nearly half of the direct care workforce  and are more likely than men or white women to rely on some form of public assistance, such as food and nutrition assistance.  Higher wages and benefits have been shown  to improve recruitment outcomes and retention rates in long-term care settings, and  state Medicaid programs have significant leverage  as the primary payer for long-term care. At least  19 states  are leveraging Medicaid reimbursement to increase provider payment rates and wages in long-term care settings.  

Modal title

• NCSL on CMS Issues Proposed Staffing Standards for Long-Term Care Facilities NCSL (Sept. 2023)
• NCSL on Ensuring Quality of Care in Long-Term Care Facilities NCSL (July 2023)
• NCSL on Strengthening the Direct Care Workforce NCSL (Feb. 2023)
• NCSL on Addressing Nursing Shortages: Options for States NCSL (2022)

Contact NCSL

For more information on this topic, use this form to reach NCSL staff.

• What is your role? Legislator Legislative Staff Other
• Is this a press or media inquiry? No Yes
• Admin Email

Related Resources

Food safety, artificial intelligence & health care: a primer, scope of practice policy.

Assisted Living

• Memory Care
• Nursing Homes
• All Senior Living
• All Senior Care
• For Caregivers
• Senior Products and Services
• Senior Living

A Guide to Nursing Home Requirements for Seniors

It’s natural for your health care needs to increase with advancing age, and eventually, you might need to find a nursing home that can deliver the care you need. Unfortunately, it can be confusing and difficult to research nursing home care on your own and to find a place that’s right for you. This guide is meant to help with your search.

If you’re one of the  1.3 million seniors who need the care that 24-hour nursing provides, or if you’re the family member of an older adult who needs help finding good nursing home care, this article can help you know what to look for, assess costs and pick a facility that’s a good fit for your situation.

• What Qualifies a Person for a Nursing Home? 

There is no universally agreed-upon set of criteria for who should be admitted to a nursing home and who should not be, but a standard of sorts has developed around the Medicaid standard for when nursing home services will be covered for beneficiaries. Each state sets its own standards and details vary, but in general, a person may be admitted to a nursing home if they have:

• Limited physical ability: People with disabilities are potentially eligible for admission to a nursing home. The disabilities may be a serious impairment, or they may be instrumental. A person whose disabilities interfere with activities of daily living, such as bathing, dressing or meal preparation, may require admission for basic safety and health reasons. 
• Health or medical needs:  People with special medical needs or chronic health conditions may need skilled nursing care from the inpatient environment of a nursing home. The health issue can be almost anything that your doctor and your state consider disabling or potentially hazardous without skilled nursing care. 
• Cognitive impairment: Seniors with cognitive impairments sometimes need the 24-hour supervision and mental health therapy available in a nursing home. This may be due to Alzheimer’s disease, Huntington’s chorea or advanced Parkinson’s disease dementia. 
• Behavioral issues:  Disturbed or irregular behavior can drive the decision to seek nursing home placement. A senior who gets confused and wanders, seeks escape from indoor environments or gets violent without an obvious cause might only have their needs met with the personal care and expertise a nursing home offers.
• What Documents Are Needed for Nursing Home Admissions?

When you’re admitted to a nursing home, the facility needs to see certain documents . Some of these are needed in every state, some relate to payment authorization or medical decision-making and others are optional or may be produced after you’ve been admitted. To make the process go smoothly, it helps to have these documents in hand before admission:

• Doctor’s orders for admission: A nursing home requires a doctor’s recommendation. This can be as simple as a one-page form, or might even be done electronically or over the phone. The documentation is similar to a doctor’s order to admit you to the hospital.
• Doctor’s prescriptions: Your prescriptions travel with you wherever you’re being treated. Your doctor has to make sure that the medications you need are authorized for disbursal by the nursing home staff. This can also usually be done electronically.
• Detailed medical history: Your medical history is a private set of documents that describes the medical conditions you have, the treatments you’ve received, physician’s notes and several other sensitive bits of information. It almost always travels with you from one facility to another in a special envelope that has to be handed over to your caregiver upon transfer.
• Test results: The nursing staff needs to have a copy of any of your recent test results. These are likely to be in your medical history packet, but it’s good to make sure they’ve been properly transferred.
• A state-approved admission form: Every state requires a nursing home admission form to be filled out at the time of your admission. This form differs in detail from one state to another, but just about every admission includes a completed form that gets filed with the state.
• Facility admission paperwork: Just as the state tracks nursing home admissions, the facilities themselves have various forms to fill out. In many cases, you can fill these out before you arrive at the facility. You could also have a caregiver, loved one or nursing home staff member do it for you.

In addition to these required forms, you might also be asked for a few supplemental documents. These don’t usually have to be presented prior to admission, but the sooner they are on file, the better:

• Durable power of attorney: As a rule, it’s a good idea to designate a third party as your medical decision-maker. It may happen that you need treatment or transfer to another facility and are unable to give your consent. You can name somebody on a legal document to make those decisions for you if needed, and their consent will be as legally binding as yours would have been. 
• Do-not-resuscitate (DNR) orders: Many people, especially those with end-stage conditions, decide to “let nature take its course” with their health and accept a natural death. A properly filed DNR is a record of your wishes not to be resuscitated if your heart stops, and against heroic measures being taken to keep you alive if you are passing away. 
• End-of-life wishes: End-of-life care wishes are your advance statements about how you want to be treated near the end of your life and immediately after in case you’re unable to make decisions at the time. Typical wishes might be that you want hospice care at home, you want continuous, deep sedation, you wish to be cremated and so on. 
• Dietary needs: You’ll be eating meals at the nursing home, and it’s a good idea to let the staff know in advance whether you have any food allergies, sensitivities (medical or cultural) or special dietary needs. For ordinary requests, such as kosher meals, vegetarian menus only or a low-salt diet, it’s usually enough to jot your requests down and submit them, but some people prefer a more formal document.

Nursing Home Financial Assessment

As a normal part of the admission process, the care facility is likely to conduct a financial assessment. This is generally done to determine whether you’re eligible for any state or federal support while you’re in residence. This can be important since nursing homes are not allowed to ask for deposits or other out-of-pocket payments from Medicaid or Medicare beneficiaries. 

The financial assessment is in many ways similar to the application process for a mortgage. Many of the same documents and life circumstances are looked at to determine whether you need help paying for your stay. Commonly asked questions during this assessment include:

• Are you currently enrolled in Medicare Parts A, B or C? Do you plan to apply?
• Do you have supplemental insurance to cover non-Medicare costs? Are you dual-eligible for both Medicare and Medicaid?
• Do you get VA benefits, Social Security, SSI/SSDI, railroad pension benefits or other income?
• What assets do you have, such as CDs or a 401(k)?
• Have you transferred significant assets to anyone else in the last 3-5 years?
• What is your current living situation (i.e. do you own a house, rent, live with somebody, etc.)?
• How much are you paying for your mortgage or monthly rent?
• How to Choose a Nursing Home

Whatever the reason you’re going into a nursing home, and regardless of how long you plan to stay, there are some things you or your loved ones should look for in any place you’re seriously considering admission to. 

• Nursing Home Laws By State

Click on your state on the map below to learn about nursing home laws in your state. 

• The Cost of Nursing Homes

Nursing home care in the United States costs an average of $7,908 a month for a semiprivate room, according to Genworth’s 2021 Cost of Care Survey . This rises to $9,034 for private rooms. This is a national figure, and the true cost of a room varies widely between states, as well as between urban areas within states. Care costs in the District of Columbia, for example, average $10,494 a month for both private and semiprivate rooms, while nursing home care in Louisiana can be as low as $5,759 for semiprivate rooms and $6,060 for private ones.

There’s even more cost variation between types of senior care. For some people, especially seniors who don’t quite need the full spectrum of care a nursing home provides, other types of living arrangements might be more affordable and more appropriate. This table lists common costs for different care levels:

Level of Care

National Median Cost (Monthly)

Nursing Home (semiprivate room)

Nursing Home (private room)

Home Health Care

• How to Pay For Nursing Home Care

Medicare commonly pays for nursing home care , both for established beneficiaries and for adults who have certain chronic conditions, such as end-stage renal disease . Under Original Medicare Part A, the inpatient benefit, the program pays for medically necessary services for a limited time. Medicare-covered services include:

• Lodging in a semiprivate room
• Meals, including special menu requirements
• Nursing care
• Physical, occupational and speech therapy
• Medically necessary social services
• Prescription medication
• Durable and disposable medical supplies
• Medically necessary transportation by ambulance
• Nutritional counseling and diabetes education

These benefits are available for a maximum of 100 days per benefit period, with a sliding scale of cost sharing. Your stay’s share of cost falls into three categories:

Share of Cost

Days 1 - 20

$0 coinsurance

Days 21 - 100

Up to $200 coinsurance per day

No coverage

Seniors who have the minimum necessary work credits are generally eligible for Medicare Part A at no cost. Other parts of Medicare have a monthly premium and may be opted out of for other coverage.

You can learn more about Medicare coverage limits at Medicare.gov .

Medicaid is a low-income health insurance program that helps provide medically necessary services for millions of seniors nationwide. All medically necessary services are included under your Medicaid benefit, with some variation in copayment amounts based on your ability to pay. This includes all doctor-authorized services provided while you’re staying at a nursing home.

Every state sets its own eligibility requirements for who can sign up for Medicaid. You generally need to have a qualifying low income and limited personal assets with some kind of medical need, such as being over age 65.

Click on your state on the map below to learn about your Medicaid eligibility requirements.

Pennsylvania

North carolina, massachusetts, south carolina, connecticut, mississippi, west virginia, new hampshire, rhode island, south dakota, north dakota.

Medicaid Eligibility

*All monthly income except for a $35/mo. personal needs allowance and Medicare premiums must be paid to the facility as a share of cost. There may also be a monthly needs allowance for a non-applicant spous.

**Income limit is for applicant only.

*Except for a $50/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

*All monthly income except for a $130 personal needs allowance and Medicare premiums must be paid to the facility as a share of cost. There may also be a monthly needs allowance for a non-applicant spouse.

***Income is limited to $2,742 per month per spouse.

*** Income is limited to $2,742 per month per spouse.

****In addition to the asset limits listed, Pennsylvania allows an extra $6,000 exemption. However, if an applicant has income more than $2,523/mo., the asset limit is $2,400 rather than the total asset limit of $8,000 ($2,000 plus $6,000 disregard).

*****Assets are limited to $2,000 per spouse

*All monthly income except for a $30/mo. personal needs allowance and Medicare premiums must be paid to the facility as a share of cost. There may also be a monthly needs allowance for a non-applicant spouse, .

*Income must be less than the amount Medicaid pays for nursing home care. Estimated cost is $6,381 – $9,087/mo. Except for a $30/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

*Except for a $60/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

***Income is limited to $2,742 per month per spouse. 

*Except for a $40/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

*Except for a $100/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

*All monthly income except for a $137.10/mo. personal needs allowance and Medicare premiums must go toward nursing home costs. There may also be a monthly needs allowance for a non-applicant spouse, .

** Income limit is for applicant only.

*** Income is limited to $2,742 per month per spouse. 

**** $2,000 per spouse

*Except for a $72.80/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care. 

***$2,000 per spouse

* Except for a $50/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care. **Income limit is for applicant only. ***Income is limited to $2,742 per month per spouse.  ****Assets are limited to $2,000 per spouse

*All monthly income except for a $52 personal needs allowance and Medicare premiums must be paid to the facility as a share of cost. There may also be a monthly needs allowance for a non-applicant spouse, .

*Except for a $93/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care. 

**The initial asset limit is $3,000 per spouse. After six months, this limit goes to $2,500 per spouse.

*Except for a $45/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

*All monthly income except for a $95.97/mo. personal needs allowance and Medicare premiums must be paid to the facility as a share of cost. There may also be a monthly needs allowance for a non-applicant spouse, .

***Asset limit is $4,000 per couple if sharing a room and $3,000 if in separate rooms.

*Except for a $121/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

*Except for a $30/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

*All monthly income except for a $30/mo. personal needs allowance and Medicare premiums must go toward nursing home costs. There may also be a monthly needs allowance for a non-applicant spouse, .

****$2,000 per spouse

*All monthly income except for a $38 personal needs allowance and Medicare premiums must be paid to the facility as a share of cost. There may also be a monthly needs allowance for a non-applicant spouse,

*All monthly income except for a $40 personal needs allowance and Medicare premiums must be paid to the facility as a share of cost. There may also be a monthly needs allowance for a non-applicant spouse.

*Except for a $74,75/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

*Except for a $75/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

***Assets are limited to $2,000 per spouse

*All monthly income except for a $60/mo. personal needs allowance and Medicare premiums must be paid to the facility as a share of cost. There may also be a monthly needs allowance for a non-applicant spouse.

***Limit is $1,600 per spouse

**Assets are limited to $2,000 per spouse

*All monthly income except for a $50 personal needs allowance and Medicare premiums must be paid to the facility as a share of cost. There may also be a monthly needs allowance for a non-applicant spouse.

****After six months of Medicaid eligibility, the rules for married couples change. They can then can choose to be considered as single applicants, which would change the asset limit to $2,000 each spouse.

*Except for a $35/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

*All monthly income except for a $137.10/mo. personal needs allowance and Medicare premiums must go toward nursing home costs. There may also be a monthly needs allowance for a non-applicant spouse.

** Income limit is for applicant only.

*** Income is limited to $2,742 per month per spouse.

* Except for a $44/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

* Income in excess of $62/mo. must go toward nursing home costs. There are exceptions for private health insurance and potentially a spousal income allowance for a non-applicant spouse.

* Except for a $83/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

****Assets are limited to $2,000 per spouse

***Assets are limited to $4,000 per spouse

*All monthly income except for a $40/mo. personal needs allowance and Medicare premiums must be paid to the facility as a share of cost. There may also be a monthly needs allowance for a non-applicant spouse.

***The limit is $2,000 each but may vary on a case-by-case basis.

*All monthly income except for a $50/mo. personal needs allowance and Medicare premiums must be paid to the facility as a share of cost. There may also be a monthly needs allowance for a non-applicant spouse, .

*Except for a $74/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

****Assets are limited to $2,500 per spouse

*All monthly income except for a $40 personal needs allowance and Medicare premiums must be paid to the facility as a share of cost. There may also be a monthly needs allowance for a non-applicant spouse,

****The asset limit is technically $2,000 for an individual and $3,000 for a couple. However, Maine allows an extra exemption of $8,000 in savings for an individual and $12,000 for a couple. 

*****The $15,000 asset limit is for couples sharing a room in the same facility. For those in separate rooms or different facilities, the asset limit is $10,000 each, for a total of $20,000.

****Assets are limited to $4,000 per spouse.

* Except for a $60/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

*Except for a personal needs allowance of $65/mo. for single and $130/mo. for couples who are both recipients, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

*;Except for a $72.66/mo. personal needs allowance, Medicare premiums and possibly a spousal income allowance for a non-applicant spouse, all of a recipient’s monthly income must be put toward the cost of nursing home care.

Veterans Benefits

The VA pays some or all of the cost for many medically necessary nursing home services. Benefits cover some of the most common costs, such as nursing care and therapeutic services. Partial coverage may be provided for some services, though this varies with your service status, disability status and ability to pay. VA benefits may be combined with Medicare and Medicaid for better coverage.

You may be able to access VA inpatient benefits if you are otherwise eligible for VA care at a hospital. If you are a qualifying veteran, your case manager can tell you more about your specific benefits.

Learn more about the VA’s nursing home benefits at VA.gov . 

Private Insurance

Many private health insurance plans have some nursing home benefits. These vary widely by company, plan and even by location. Be sure to ask your plan representative for definitive information about your benefits.

• Table of Contents

Speak with a Caring Family Advisor

Our experts can help find the community or care you need in your area — all at no cost to you.

Request Sent!

A member will contact you within 24 hours to assist with any and all of your needs.

(855) 240-7757

Oops, it looks like we made a mistake.

We’re sorry, but there was an issue with your request for information about senior care services.

To get connected with a Family Advisor, please call

• Older Adults
• Professionals
• Explore NCOA.org
• Get Involved
• Best Hearing Aids
• Best OTC Hearing Aids
• Most Affordable Hearing Aids
• Best Medical Alert Systems
• Best Fall Detection Devices
• Life Alert Review
• Best Portable Oxygen Concentrator
• Best Mattress
• Best Mattress for Back Pain
• Best Adjustable Beds
• Best Walk-In Tubs

Find us on Social

The NCOA Adviser Reviews Team researches these products & services and may earn a commission from qualified purchases made through links included.

The NCOA Adviser Reviews Team researches these products & services and may earn a commission from qualified purchases made through links included. NCOA does not receive a commission for purchases. If you find these resources useful, consider  donating to NCOA .

Nursing Homes: A Comprehensive Guide

Key takeaways.

• Nursing homes, also called skilled nursing facilities, are for older adults in need of short or long-term care, which can no longer be provided at home or in an assisted living facility.
• Services provided in nursing homes range from personal care, like helping older adults with activities of daily living (ADLs) ⓘ Activities of daily living, also called ADLs, are activities related to necessary personal care. These include bathing, dressing, toileting, eating, walking, and transferring in and out of a bed or chair. , to skilled nursing care, such as wound care or diabetes management.
• Medicare will help pay for up to 100 days of rehabilitation in a skilled nursing facility, but it will not pay for long-term care. Medicaid is the primary payer of nursing home care for older adults who qualify.

Nursing home facilities offer short-term and long-term solutions for older adults needing specialized care outside the home. But the nursing home landscape can be confusing.

You might be approaching this big life decision with unanswered questions: Do my needs require a nursing home level of care? Will Medicare cover my nursing home stay? Do I need assisted living , or is a nursing facility a better option? How will I pay for it?

In this comprehensive guide, our Local Care Reviews Team explains what a nursing home is and lets you know what to expect regarding cost, services, and how to determine if a nursing home is right for the kind of care you need.

Why you can trust our expert review

Our team works hard to provide clear, transparent information to older adults seeking senior living and home care. To provide you with the best possible information, we have spent more than 250 hours:

• Consulting with our advisory board, which consists of a certified life care manager, a board-certified geropyschologist ⓘ A geropyschologist is a professional psychologist who specializes in the needs and well-being of older adults. , and a geriatric nurse practitioner
• Analyzing and synthesizing nationwide data from the Centers for Medicare & Medicaid Services ( CMS ), the National Investment Center for Seniors Housing & Care ( NIC ), and the National Center for Assisted Living ( NCAL )
• Analyzing and synthesizing state-specific data from government health regulatory agencies
• Surveying thousands of older adults and their caregivers about their search for senior living facilities
• Conducting focus groups with caregivers helping older adults find assisted living
• Mystery shopping dozens of brands and facilities associated with long-term care for older adults

What is a nursing home?

Nursing homes offer the highest level of care in the spectrum of senior living options. With both short-term and long-term residential care, nursing homes are designed for older adults requiring ongoing medical attention and assistance with most or all activities of daily living (ADLs), such as bathing and getting in and out of bed. A nursing home may be a good option if you or someone you care for has a chronic disease, significant physical or cognitive decline, or complex medical needs that cannot be managed at home.

What is a skilled nursing facility?

In the long-term care community, the terms skilled nursing facility and nursing home are used interchangeably. In addition to skilled nursing, nursing homes provide rehabilitation and personal care ⓘ Personal care, sometimes called custodial care, refers to non-medical care provided by professional caregivers, such as assistance with bathing or toileting. .

• Skilled nursing may include wound care, managing an insulin pump, or any care provided by or performed under a registered nurse’s (RN) supervision.
• Rehabilitation needed as the result of an injury, disease, or disability can also be provided in a nursing home. These services may include physical therapy, occupational therapy, or speech therapy.
• Long-term care in a nursing home is defined by Medicaid as “health-related care and services (above the level of room and board) not available in the community, needed regularly due to a mental or physical condition.” Long-term care may include skilled nursing and rehabilitation, dementia-specific care, or assistance with activities of daily living (ADLs), like bathing and bed transfer. [1] Nursing Facilities. Medicaid.gov. Found on the internet at https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/nursing-facilities/index.html

Do all nursing home facilities offer memory care?

The Alzheimer’s Association reported 58% of long-stay nursing home residents have Alzheimer’s or another form of dementia. [2] Alzheimer’s Association. 2023 Alzheimer’s Disease Fact and Figures. Found on the internet at ​​https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf Many, but not all facilities, will have a dedicated memory unit or floor. When you tour facilities, ask about the availability of memory care and whether staff receive dementia-specific training.

Nursing home facilities for long-term care

When an older adult reaches a level of care no longer available at home or in an assisted living community, it might be time for long-term nursing care.

Long-term care received in a nursing home setting is often made up of:

• Medication management and administration
• Assistance with ADLs, such as bathing, toileting, and transferring to and from bed or a wheelchair
• Skilled nursing care, such as wound care, catheter care, blood pressure monitoring, and injections
• Attention to one’s overall health and well-being, including prepared meals and social activities

Nursing home facilities for short-term care

After a qualifying inpatient hospitalization, older adults may require a short stay in a nursing home, often called rehabilitation or rehab. All nursing home residents can receive skilled nursing care, regardless of the length of their stay. Short-term residents will also receive prepared meals, medication management, and as-needed help with ADLs.

Short-term care received in a nursing home setting often consists of:

• Physical, occupational, or speech therapy to help someone recover from an illness, injury, or stroke
• Physical and occupational therapy to help restore mobility, strength, and endurance
• Social and psychological services

The Green House model of nursing home care

The Green House® Project (GHP) aims to create non-institutional eldercare environments to empower residents and those caring for them. Green House homes, the majority of which are licensed skilled nursing facilities, are small in scale with private rooms and bathrooms, living rooms, and other features differentiating them from traditional institutional care settings. Currently, 400 Green House homes exist in 32 states. [3] The Green House Project. Build Green House Homes. Found on the internet at https://thegreenhouseproject.org/solutions/build-a-green-house/ A Green House may be the preferred model for those who like a smaller and more home-like environment compared to traditional nursing homes.

Nursing Home Level of Care and services

For an older adult to qualify for skilled nursing care, a health care professional must indicate a need for a Nursing Home Level of Care (NHLOC).

What do I need to know about nursing home level of care?

• NHLOC has no universal definition across all 50 states. Each state defines this level of care differently, and definitions can be complex. For example, one of the criteria for NHLOC in North Carolina is the need for a registered nurse (RN) for a minimum of eight hours each day. [4] NC Division of Medical Assistance Nursing Facilities. Medicaid and Health Choice: Clinical Coverage Policy No: 2B-1. Found on the internet at https://files.nc.gov/ncdma/documents/files/2B1.pdf In other states, the criteria are more general. Pennsylvania’s primary criteria for nursing home eligibility, for example, is a diagnosis and required treatment impacting an individual’s physical and/or psychological ability to manage their care. [5] Long Term Living Training Institute of Pennsylvania. Pennsylvania Department of Aging. Level of Care Determination. Found on the internet at https://www.aging.pa.gov/organization/licensing-and-monitoring/Documents/LCD%20Supervisor%20Workbook%207%2011%2013%20(1).pdf
• NHLOC is used to determine Medicare and Medicaid funding. In most cases, a physician must determine whether a person is eligible for NHLOC, according to state standards, before Medicare or Medicaid will approve funding.
• Older adults usually qualify for NHLOC due to a combination of medical, cognitive, behavioral, and functional factors. For example, someone l may meet the requirement for nursing home care if they demonstrate a need for medical assistance, such as help with a CPAP machine or catheter, and functional assistance, such as help with ADLs.
• The term for NHLOC is different across states. It may also be referred to as Nursing Facility Level of Care (NFLOC), Nursing Facility Clinically Eligible (NFCE), or Level of Care Determination (LOCD).

What services are provided at skilled nursing facilities?

The services provided in a nursing home partially depend on the requirements of NHLOC in the state where the facility is located. However, general federal guidelines for services provided in nursing homes offer oversight for skilled nursing as a whole. [6] Medicaid.gov. Nursing Facilities. Found on the internet at https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/nursing-facilities/index.html

Nursing homes are federally required to provide the following services to residents:

• Skilled nursing and related services
• Rehabilitation services to support and maintain the physical and mental health of residents
• Medically related social services, such as making arrangements for adaptive equipment
• Pharmaceutical services
• Customized dietary services
• Social activities to support the psychosocial needs of residents
• Regular and emergency dental services
• Personal hygiene items and services
• Assistance with ADLs, such as bathing and toileting, when residents cannot perform these tasks on their own

Based on the need of residents, nursing homes may also provide the following services : [7] Title 42 of the Code of Federal Regulations. Part 483-Requirements for States and Long Term Care Facilities. Found on the internet at https://www.govinfo.gov/content/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5.pdf

• Maintenance of vision or hearing abilities, including assistive devices like hearing aids
• Treatment for and prevention of pressure sores
• Treatment to increase or maintain range of movement, including physical therapy and ambulatory devices, such as walkers
• Treatment to maintain mental and psychosocial health
• Supervision of medical care by a physician or advanced practice provider ⓘ An advanced practice practitioner (APP) is a medical provider, such as a nurse practitioner (NP) or physician’s assistant (PA), with training similar to a physician’s. APPs work in all areas of hospitals and clinics under a physician’s supervision and can prescribe medications and order tests for all procedures.
• Transportation for specialized medical or therapeutic care

Most nursing homes do not provide: services like television and telephone; personal comfort items, including candy and tobacco products; cosmetic products and services beyond those included in basic service; personal clothing; personal reading materials; flowers or plants; and social events beyond what is offered by the facility. These items and services will usually need to be provided by the resident or the resident’s family.

Nursing homes compared to other senior care options

On the spectrum of long-term residential care options for older adults, nursing homes offer the highest level of care. To determine which housing option is right for you or someone you care for, you should know what each setting offers.

Assisted living vs. nursing homes

Assisted living is ideal for older adults who need help with certain ADLs but still want to live independently. In an assisted living community, residents live in a private or shared apartment and enjoy communal meals, daily social activities, and as-needed 24/7 care for medication management and help with ADLs, such as bathing and dressing.

Unlike nursing homes, assisted living facilities do not require a registered nurse on staff, so they do not offer ongoing medical care to residents. According to the National Center for Assisted Living, 60% of assisted living residents will transition to a skilled nursing facility after a median stay of 22 months . [8] American Health Care Association / National Center for Assisted Living. Assisted Living Facts & Figures. Found on the internet at https://www.ahcancal.org/Assisted-Living/Facts-and-Figures/Pages/default.aspx This is usually due to an increased need for medical care or help with more ADLs, such as bed transferring or toileting.

Nursing homes vs. memory care facilities

Memory care units are often co-located in assisted living or are stand-alone memory care facilities. If someone living with Alzheimer’s or another form of dementia can perform most activities of daily living without additional assistance, a locked memory care unit in an assisted living facility may provide a sufficient level of care. But as an individual’s dementia progresses, symptoms like incontinence, difficulty feeding oneself, or behavioral disturbances such as aggression may require transitioning to a skilled nursing facility.

Home care vs. nursing homes

In-home care is often more personalized and less expensive than nursing home care, although it may require someone living in the home to be a full-time caregiver, which can be a financial and emotional strain. While skilled nursing can be delivered in both settings, older adults aging at home won’t have 24/7 access to a registered nurse, as they would in a nursing home.

Table 1 Nursing homes vs. other types of residential care for older adults

* Skilled nursing is available in memory care if the unit is in a skilled nursing facility.

When is a nursing home the right choice?

Many older adults wish to maintain their independence as long as possible, and a nursing home might not be a first choice. But if you or someone you care for needs more care than a home setting or assisted living facility can provide, a nursing home might be the best option.

Key signs indicating the need for nursing home care

A nursing home might be the right choice if you or someone you care for has:

• A history of falls, mobility issues increasing the risk of a fall, or further needs for falls prevention
• Decreased ability to complete ADLs, such as bathing or toileting, without assistance
• An ongoing or new medical diagnosis, such as dementia, stroke, or diabetes, which can no longer be managed at home but does not require hospitalization
• Significant memory loss or decreased cognitive function
• A recent hospital stay requiring subsequent rehabilitation or skilled nursing care
• A need for around-the-clock care or supervision

Essential qualifications for nursing home care

If you or someone you care for needs nursing care, the nursing home will require a referral from a licensed physician or advanced practice provider. This referral form is different in every state, but it usually confirms current diagnoses and provides an overview of the patient’s functional status, such as their inability to perform ADLs.

In addition to the referral form, potential nursing home residents will need to provide a current list of medications, submit a negative TB test, and finalize payment arrangements with the nursing facility staff.

The most direct way to find placement in a nursing home is directly following a hospital stay or a rehab placement following a hospital stay.

Six benefits of nursing home facilities

1. assistance with activities of daily living.

Personal care, or non-medical care provided by professional caregivers, is available to all residents of nursing homes. This includes assistance with ADLs, like bathing, dressing, and toileting.

2. Around-the-clock access to care

In a nursing home, registered nurses (RNs) are available 24/7 to address residents’ skilled nursing needs, such as wound or catheter care.

3. Socialization opportunities

Social engagement is critical to everyone’s overall well-being. Nursing homes provide regular interaction with peers through communal meals and meaningful social activities, like concerts and craft projects. However, the activities and socialization opportunities vary significantly from nursing home to nursing home. Take the time to inquire about the type and frequency of social activities offered.

4. Nutritious diet

Nursing homes provide three balanced meals per day and can customize diets according to a resident’s medical needs.

5. Specialized care and services

In a nursing home, you can receive specialized medical and personal care services. Nursing staff are required by federal law to regularly assess residents and determine changes in resident status and which services are needed, from help with daily activities to diabetes monitoring.

6. Greater opportunity for Medicare and Medicaid coverage

Medicare won’t pay for long-term care, but it will cover most short-term stays of up to 100 days in nursing facilities. Also, in most states, you’re much more likely to receive Medicaid coverage for a nursing home than for an assisted living facility if you qualify.

In my experience…

“The primary advantage of nursing homes over assisted living or in-home care services is the relatively quicker availability of on-site skilled nursing services. This doesn’t mean that in a nursing home someone will be at your side the moment you pull your call light, but skilled care is available more readily. Skilled nursing facilities have at least one registered nurse on-site at all times, whereas assisted living facilities are not typically staffed with RNs, and in the case of in-home care, an RN needs to travel to your residence if skilled services are needed. In skilled nursing facilities, there are still holes in the safety net, but those holes are perhaps smaller and further apart than in other care settings.”

– Christopher Norman, Geriatric Nurse Practitioner, and Holistic Nurse

Understanding the costs associated with nursing homes

The monthly median cost for a nursing home facility in the United States is $7,908 for a shared room and $9,034 for a private room. [9] Genworth. Cost of Care Survey. Found on the internet at https://www.genworth.com/aging-and-you/finances/cost-of-care.html For many Americans, this is not a manageable out-of-pocket expense.

Nursing homes offer the highest level of care on the spectrum of residential housing options for older adults, but also come with the highest price tag. However, more government funding options are available for nursing homes than for other types of senior living.

Table 2 The cost of nursing homes vs. other types of senior care

Source: Genworth Cost of Care Survey and Dementia Care Central [9] Genworth. Cost of Care Survey. Found on the internet at https://www.genworth.com/aging-and-you/finances/cost-of-care.html [10] Dementia Care Central. Alzheimer’s / Dementia Care Costs: Home Care, Adult Day Care, Assisted Living & Nursing Homes. Updated February 2023. Found on the internet at https://www.dementiacarecentral.com/assisted-living-home-care-costs

*This number reflects the monthly cost of professional in-home care provided for 44 hours per week.

Payment options and financial assistance for nursing homes

If you’re considering nursing home care for yourself or someone you care for, the cost is a genuine concern. While more aid is available for nursing homes than other types of senior housing, Medicaid policies and coverage will vary depending on where you live.

Here’s an overview of the ways people pay for nursing home care:

Private pay

Methods of private pay for nursing home residents include personal savings, Social Security benefits, proceeds from the sale of a home or stocks, 401(k) or IRA accounts, or financial assistance from friends or family members.

In most cases, older adults with long-term care insurance can be reimbursed for the cost of nursing home care. Some policies come with an initial out-of-pocket period, so if you begin nursing home care before the out-of-pocket period has expired, you could be facing thousands of dollars in non-reimbursable expenses. Know the details of your policy and the length of any out-of-pocket period.

Some older adults sell their life insurance policies to pay for nursing home care. This can occur through life settlements or accelerated death benefits. Life settlements allow policyholders to sell their policy for the cash value of the death benefit. In this arrangement, you may not receive the benefit’s total cash value. This is also true for accelerated death benefits, which are tax-free advances on a policy’s death benefit, often capped at 50% of the policy’s full benefit. [11] LongTermCare.gov. Using Life Insurance to Pay for Long-term Care. Found on the internet at https://acl.gov/ltc/costs-and-who-pays/who-pays-long-term-care/using-life-insurance-to-pay-for-long-term-care Always talk with a trusted financial advisor before making this kind of financial decision.

Government funding

Medicare, Medicaid, and the Department of Veterans Affairs (VA) can help to cover the cost of nursing home facilities for older adults. [12] Kaiser Family Foundation. Medicaid’s Role in Nursing Home Care. Found on the internet at https://www.kff.org/infographic/medicaids-role-in-nursing-home-care/ The Kaiser Family Foundation reported that Medicaid pays for the majority of long-term nursing home care, with 6 in 10 residents relying on Medicaid coverage . However, you must qualify for Medicaid to receive coverage.

Table 3 Primary government insurance programs to pay for nursing home care

Source: [13] U.S. Department of Veterans Affairs. VA nursing homes, assisted living, and home health care. Found on the internet at https://www.va.gov/health-care/about-va-health-benefits/long-term-care/

Understanding Medicare coverage for nursing home care

Medicare is a national health care program with federal oversight, so the rules for Medicare coverage of nursing home care are the same in every state.

These are the Medicare guidelines for coverage of services received in a skilled nursing facility:

• Medicare will not pay for any form of long-term care, including nursing home care.
• Medicare will help cover the first 100 days of care received in a skilled nursing facility.

Specifically, the rules for Medicare coverage of skilled nursing are as follows:

• Medicare covers skilled nursing facility stays only after a person has been a hospital inpatient for at least three days.
• For days 1-20, services are entirely covered by Medicare.
• For days 21-100, the Medicare beneficiary may be responsible for up to $200 per day.
• For days 101 and beyond, the Medicare beneficiary is responsible for 100% of costs. [14] Medicare.gov. Skilled nursing facility (SNF) care. Found on the internet at https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care

How to choose and move into a nursing home

Because nursing homes are both medical and residential facilities, they may not feel as inviting as other senior living options, such as assisted living or independent living. To find a place where you or someone you care for can receive quality care, look beyond aesthetics and focus on issues of staffing and availability of services.

Narrowing down your nursing home search

Touring nursing homes can be an overwhelming experience. Before you begin, narrow your search to a handful of facilities.

These tips can help you narrow your nursing home search:

• Find facilities in locations where friends and family can visit frequently. Frequent visits improve the quality of life for nursing home residents and show staff your involvement in your friend or family member’s care.
• Learn about the Centers for Medicare & Medicaid Services’ Five-Star Quality Rating System and find the quality rating for the facilities you’ll visit. [15] Centers for Medicare & Medicaid Services. Five-Star Quality Rating System. Found on the internet at https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/fsqrs
• Visit Medicare’s Nursing Home Comparison tool to compare local nursing homes and learn about their quality of care, staffing ratios, and more.
• Make a list of what’s most important to you in a nursing facility, such as access to skilled nurses, daily social engagement, or dementia-specific care. Refer to this list as you begin to tour facilities.

Evaluating staffing and care standards in a nursing home

Unfortunately, nursing homes often experience staffing shortages. The Kaiser Family Foundation reported 24% of nursing facilities in the United States experienced staffing shortages as of March 2022. [16] Kaiser Family Foundation. Nursing Facility Staffing Shortages During the COVID-19 Pandemic. Found on the internet at https://www.kff.org/coronavirus-covid-19/issue-brief/nursing-facility-staffing-shortages-during-the-covid-19-pandemic/ You can make a difference in the nursing home experience of someone you care for by staying involved in their care plan and getting to know the staff caring for them.

Ask about these staffing and care standards when you tour a nursing facility:

• The mix of nursing staff is a key metric in understanding the staffing competencies of a particular facility. For example, a facility could have plenty of certified nursing assistants (CNAs) but only one registered nurse (RN) delivering skilled nursing care. This could be problematic for residents with feeding tubes or other medical devices requiring monitoring by an RN.
• Management of each resident’s care plan is another vital factor in the quality of care received in a nursing home. Older adults’ social, emotional, and medical needs will change over time, and the care plan will need to be updated accordingly. Check with the nursing staff at the facilities you tour to find out how often care plans are updated, and how family members are included in the process.
• Safety and well-being checks throughout the day help keep nursing home residents safe, comfortable, and engaged. Ask how often the staff performs these checks and what they entail.

Ensuring quality of life and care in a nursing home

Nursing home residents deserve to live meaningful lives and to be treated with dignity. To help ensure someone you care for is living well in a nursing home, pay attention to the quality of social activities and look for signs of elder abuse.

• Social connection is essential to everyone’s overall well-being. When touring facilities, look for community gathering areas where residents engage with one another. Are residents sitting in wheelchairs or sleeping at the nurses’ station? This may mean social engagement is lacking. Talk with residents about their experiences and, if possible, ask to speak to the activities director.
• Know the signs of elder abuse and have a plan to address any issues. To report elder abuse, get in touch with Adult Protective Services in your state, contact your state’s Long-Term Care Ombudsman , or if someone is in immediate danger, call 911.

Planning for the transition to a nursing home

People often enter nursing homes following an unexpected hospital stay, making it challenging to plan for the transition. Still, you can help someone you care for make the transition, even if they’ve already been living in a nursing home for a few days or weeks.

Tips for a smooth transition to a nursing home

• If possible, help the person you care for to emotionally prepare for the move by talking to them about it in advance. Show photos of the facility, if you have any, and talk through any worries they may have about the move.
• Bring personal belongings to make the nursing facility feel more like home. These items might include family photographs, plants, or a preferred bedspread or blanket. Use a permanent marker or fabric labels to label all belongings.
• Help the person you care for get involved in social activities as soon as possible. If you can, attend a few of the facility’s activities with your friend or family member to help them get used to the new environment.
• Be their advocate. Check in frequently with your friend or family member and ask them how they feel. Help them talk with nursing home staff about any issues.
• Attend family nights and meetings. Most nursing homes have regular family nights or update meetings. This is a great opportunity to learn about happenings in the facility, such as staffing changes. You can also use this time to bring issues to the administration’s attention and discuss potential problems and solutions.

Resources for finding a nursing home near you

If you’ve determined a nursing home is the right option for you or someone you care for, the next step is selecting a nursing facility to meet your needs. Work with friends and family members to make this decision, and draw from the community resources available to you.

Strategies for researching nursing homes near me

Many older adults are admitted to nursing homes after a stay in the hospital. In this case, ask the hospital social worker or discharge planner to provide a list of nursing homes in your community. Ask for advice and recommendations from friends and family members with experience searching for nursing homes, or direct experience with local nursing homes.

Finally, don’t rely solely on word of mouth, an internet search, or even a star rating to determine the quality of a nursing home. Visit the facilities yourself to learn about the kind of care provided.

List of nursing home resources

This list of resources can help you find the information you need about nursing homes and the care provided there:

• BenefitsCheckUp : Discover your coverage options.
• Medicare Care Compare : Find and compare nursing homes near you.
• Eldercare Locator : Locate the Area Agency on Aging near you, and find other resources supporting older adults in your community.
• Caregiver Action Network : Connect with other family caregivers and find support.
• Rights and Protections as a Nursing Home Resident : Familiarize yourself with the Centers for Medicare & Medicaid’s Rights and Protections for Nursing Home Residents.

Bottom line: making informed decisions about nursing homes

Nursing homes provide complex, comprehensive care for older adults who can no longer be cared for at home, but do not require hospitalization. In both short-term and long-term residential settings, nursing homes provide a range of services like: help with ADLs, like bathing and getting in and out of bed; rehabilitation services, like physical and occupational therapy; and skilled nursing services, such as wound or catheter care.

Compared to other senior living options, nursing homes are the most expensive and offer the highest level of care. Most nursing homes offer some form of memory care for residents with Alzheimer’s or another form of dementia. Each state has different standards for how a person qualifies for skilled nursing care. People usually qualify due to a combination of medical, cognitive, behavioral, and functional factors.

If you or someone you care for needs nursing home care, tour facilities before making a final decision. During your tours, talk to as many people as possible, and ask a lot of questions. Seek out community resources, and enlist friends and family members to help with decision-making. Moving to a nursing home is a major life transition. You don’t have to go through it alone.

Frequently asked questions

Medicare does not cover long-term care, including nursing homes, but it will help to pay for up to 100 days of rehabilitation in a skilled nursing facility following a three-night hospital stay.

The monthly median cost for a nursing home facility in the United States is $7,908 for a shared room and $9,034 for a private room.

To qualify for nursing home care, a physician must determine whether a person meets state standards for Nursing Home Level of Care (NHLOC). Each state defines NHLOC differently, but it usually requires a person to have a combination of medical, cognitive, behavioral, or functional needs.

Medicare will help pay for up to 100 days of rehabilitation in a skilled nursing facility. After the first 100 days, the patient is responsible for 100% of nursing home costs. Medicaid can help pay for nursing homes for those who meet the income requirements. Other options include personal savings, proceeds from the sale of a home or life insurance policy, long-term care insurance, or VA benefits.

Have questions about this article? Email us at [email protected] .

• Nursing Facilities. Medicaid.gov. Found on the internet at https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/nursing-facilities/index.html
• 2023 Alzheimer’s Disease Fact and Figures. Alzheimer’s Association. Found on the internet at ​​https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf
• Build Green House Homes. The Green House Project.  Found on the internet at https://thegreenhouseproject.org/solutions/build-a-green-house/
• Medicaid and Health Choice: Clinical Coverage Policy No: 2B-1. NC Division of Medical Assistance Nursing Facilities. Found on the internet at https://files.nc.gov/ncdma/documents/files/2B1.pdf
• Level of Care Determination.Long Term Living Training Institute of Pennsylvania. Pennsylvania Department of Aging.  Found on the internet at https://www.aging.pa.gov/organization/licensing-and-monitoring/Documents/LCD%20Supervisor%20Workbook%207%2011%2013%20(1).pdf
• Part 483-Requirements for States and Long Term Care Facilities. Title 42 of the Code of Federal Regulations. Found on the internet at https://www.govinfo.gov/content/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5.pdf
• Assisted Living Facts & Figures. American Health Care Association / National Center for Assisted Living. Found on the internet at https://www.ahcancal.org/Assisted-Living/Facts-and-Figures/Pages/default.aspx
• Cost of Care Survey. Genworth. Found on the internet at https://www.genworth.com/aging-and-you/finances/cost-of-care.html
• Alzheimer’s / Dementia Care Costs: Home Care, Adult Day Care, Assisted Living & Nursing Homes. Dementia Care Central. Updated February 2023. Found on the internet at https://www.dementiacarecentral.com/assisted-living-home-care-costs
• Using Life Insurance to Pay for Long-term Care. LongTermCare.gov. Found on the internet at https://acl.gov/ltc/costs-and-who-pays/who-pays-long-term-care/using-life-insurance-to-pay-for-long-term-care
• Medicaid’s Role in Nursing Home Care. Kaiser Family Foundation. Found on the internet at https://www.kff.org/infographic/medicaids-role-in-nursing-home-care/
• VA nursing homes, assisted living, and home health care. U.S. Department of Veterans Affairs. Found on the internet at https://www.va.gov/health-care/about-va-health-benefits/long-term-care/
• Skilled nursing facility (SNF) care. Medicare.gov. Found on the internet at https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care
• Five-Star Quality Rating System. Centers for Medicare & Medicaid Services. Found on the internet at https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/fsqrs
• Nursing Facility Staffing Shortages During the COVID-19 Pandemic. Kaiser Family Foundation. Found on the internet at https://www.kff.org/coronavirus-covid-19/issue-brief/nursing-facility-staffing-shortages-during-the-covid-19-pandemic/

• Health Insurance and Medicare

What Caregivers Should Know About Nursing Home Care

What Is Long-Term Care? Long-term care refers to a comprehensive range of medical, personal, and social services coordinated to meet the physical, social, and emotional needs of people who are chronically ill or disabled. A nursing home facility may be the best choice for people who require 24-hour medical care and supervision.

What Type of Care Do Nursing Homes Provide?

Nursing homes offer the most extensive care a person can get outside a hospital. Nursing homes offer help with custodial care -- like bathing, getting dressed, and eating -- as well as skilled care. Skilled nursing care is given by a registered nurse and includes medical monitoring and treatments.

Skilled care also includes services provided by specially trained professionals, such as physical, occupational, and respiratory therapists.

What Services Do Nursing Homes Offer? The services nursing homes offer vary from facility to facility. Services often include:

• Room and board
• Monitoring of medication
• Personal care (including dressing, bathing, and toilet assistance)
• 24-hour emergency care

Social and recreational activities

How Can I Find the Right Nursing Home? Finding the right nursing home takes time. It is important to begin the search for a suitable nursing home well in advance of seeking admission to the facility. There are often long waiting periods for available accommodations. Planning ahead also can make the transition of moving into a nursing home much easier.

Talk with your family member about what services theywill need. Take time to consider what services are important  before calling different nursing homes.

Think about these questions:

• What daily activities does your family memberneed help with (bathing, dressing, toileting assistance, eating)?
• How often do theyneed help?

Before scheduling a visit to the nursing homes you are interested in, ask about vacancies, admission requirements, level of care provided, and participation in government-funded health insurance options .

How Can I Pay for Nursing Home Care? As you evaluate your family member's long-term care needs, it's important to consider financing options. Payment for nursing home care can be made through Medicare (see limitations below) , Medicaid , private insurance, and personal funds. When evaluating nursing homes, it's important to ask the administrative staff what payment options they accept. Here's a brief summary of some of the financing options.

• Medicare is a federal health insurance program providing health care benefits to all Americans age 65 and over. Insurance protection intended to cover major hospital care is provided without regard to income. Medicare will only provide up to 100 days of nursing care, and only if a person requires skilled care and is referred by a doctor when discharged from at least a 3-day stay in the hospital. If a person needs custodial care alone, Medicare won't cover it. Medicare only pays for skilled care in a nursing facility that has a Medicare license.
• Medicaid is a joint federal/state health insurance program providing medical care benefits to low income Americans who meet certain requirements. Nursing home care is covered through Medicaid, but the requirements and covered services vary widely from state to state. To become eligible for Medicaid coverage, people usually have to spend all of their assets first. This means that they might pay for nursing home care out of pocket initially. Once their money runs out, Medicaid would kick in. It's a good idea to work with a lawyer who specializes in elder law when determining Medicaid eligibility.
• Private long-term care insurance is a health insurance option that covers custodial nursing home care. Private long-term care insurance policies vary greatly. Each policy has its own eligibility requirements, restrictions, costs, and benefits.

What Should I Look for in a Nursing Home?

Medicare has a website to find and compare nursing homes in your area. After you enter your zip code, you will see a list of nursing homes. Each one is given an overall rating of 1 to 5 stars based on three factors: health inspections, staffing, and quality measures. You can click on individual nursing homes to get more information on each factor.  In addition, the following checklist will help you and your family evaluate different nursing homes. Review the following checklist before visiting a facility. Be sure to take a checklist with you.

Nursing Home Checklist

• Does the nursing home provide the level of care needed?
• Does the nursing home meet local and/or state licensing requirements?
• Does the nursing home's administrator have an up-to-date license?
• Does the nursing home meet state fire regulations (including a sprinkler system, fire-resistant doors, and a plan for evacuating residents)?
• What are the visiting hours?
• What is the policy on insurance and personal property?
• What is the procedure for responding to a medical emergency?
• Is there a waiting period for admittance?
• What are the admission requirements?

Fees and financing

• Are fees competitive?
• Have fees increased significantly in the past few years?
• Is the fee structure easy to understand?
• What are the billing, payment, and credit policies?
• Are there different costs for various levels or categories of services?
• Are the billing and accounting procedures understandable?
• Does the nursing home reveal what services are covered in the quoted fee and what services are extra?
• What governmental financing options are accepted (such as Medicare, Medicaid, Medicare Supplemental Insurance, Supplemental Security Income, and others)?
• When may a contract be terminated? What is the refund policy?

Needs assessment

• Is there a written plan for the care of each resident?
• What is the procedure for assessing a potential resident's need for services? Are those needs reassessed periodically?

Professional staff

• Do the nurses, social workers, and administrators have geriatric experience and/or education?
• Are staff members available to meet scheduled and unscheduled needs?
• Do staff members seem to genuinely enjoy working with the residents?
• Do staff members treat residents as individuals?
• Is staff available to assist residents who experience memory, orientation, or judgment losses?
• Does a doctor or nurse visit the resident regularly to provide medical checkups?
• Do residents appear happy and comfortable?
• Do residents, other visitors, and volunteers speak favorably about the nursing home?
• Are residents clean and adequately dressed?
• Are the rights of residents clearly posted?

Facility design

• Do you like the appearance of the building and its surroundings?
• Is the decor attractive and home-like?
• Is the floor plan easy to follow?
• Do doorways, hallways, and rooms accommodate wheelchairs and walkers?
• Are elevators available?
• Are handrails available?
• Are shelves easy to reach?
• Are carpets secured and floors made of a non-skid material?
• Is there good natural and artificial lighting?
• Is the residence clean, odor free, and appropriately heated/cooled?

Medication and health care

• What is the policy regarding storage of medication and assistance with medication?
• Is self-administration of medication allowed?
• Who coordinates visits from a physical, occupational, or speech therapist if needed?
• Is staff available to provide 24-hour assistance with activities of daily living, if needed? Daily activities include:
• Hygiene and grooming
• Bathing, toileting, and incontinence
• Using the telephone

Room features

• Are rooms for single and double occupancy available?
• Is a 24-hour emergency response system accessible from the room?
• Are bathrooms private? Do they accommodate wheelchairs and walkers?
• Can residents bring their own furnishings? What may they bring?
• Do all rooms have a telephone? How is billing handled for long-distance calls?
• Is there an activities program?
• Are the activities posted for residents?
• Do most of the residents at activities seem to be participating?

Food service

• Does the nursing home provide three nutritionally balanced meals a day, seven days a week?
• Is the food hot, attractive, and tasty?
• Are snacks available?
• How are special diets handled? May a resident request special foods?
• Is drinking water always accessible?
• Are common dining areas available or do residents eat meals in their rooms?
• May meals be provided at times a resident prefers or are there set meal times?
• Is assistance available for residents who need help with eating?

Residents and Atmosphere

Common terms:

Skilled nursing care: Care that is received in a nursing facility that provides 24-hour nursing care for convalescent residents and those with long-term care illnesses. It is one step below hospital acute care, and regular medical supervision and rehabilitation therapy are usually available.

Personal care: Care that is customized to the individual needs of activities of daily living; self-administration of medications.

Activities of daily living (ADL): Everyday activities that include bathing, grooming, eating, toileting, and dressing.

Instrumental activities of daily living (IADL): Include activities such as shopping, preparing meals, performing housework, laundering, heavy chores, managing finances, and yard work and maintenance.

Home health care: Medical and nursing care that is administered in the individual's home by a licensed provider.

Top doctors in ,

Find more top doctors on, related links.

• Health Insurance and Medicare News
• Health Insurance and Medicare Reference
• Health Insurance and Medicare Quizzes
• Health Insurance and Medicare Videos
• Find a Doctor
• Using Your Benefits
• Screening Tests
• Getting a Second Opinion
• Nursing Home Care
• Help Paying for Rx

An official website of the United States government.

Here’s how you know

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Misclassification
• Family and Medical Leave Act (FMLA)
• Pump at Work
• Maternal Health
• Retaliation
• Government Contracts
• Immigration
• Child Labor
• Agricultural Employment
• Subminimum Wage
• Employment of Workers With Disabilities
• Lie Detector Tests
• Davis Bacon Prevailing Wage Survey
• WORKER RIGHTS
• Resources For Employers
• Regulatory Library
• Interpretive Guidance
• Industry-Specific Resources
• Compliance Assistance
• elaws Advisors
• Fact Sheets
• New and Small Businesses Resources
• Presentations
• External User Portal (EUP)
• Compliance Assistance Toolkits
• New and Small Business Resources
• Publications By Language
• FLSA Compliance Videos
• Know Your Rights Video Series
• Employer.gov
• DOL Enforcement Database
• Workers Owed Wages
• Order Publications
• Laws and Regulations
• Field Handbook
• Administrator Interpretations, Opinion and Ruling Letters
• Field Bulletins
• State Minimum Wage Laws
• State Labor Law Topics
• State Labor Offices
• Resources for State and Local Governments
• NEWS RELEASES

WAGE AND HOUR DIVISION

UNITED STATES DEPARTMENT OF LABOR

Fact Sheet #31: Nursing Care Facilities Under the Fair Labor Standards Act

Revised July 2009

This fact sheet provides general information concerning the application of the minimum wage , overtime pay and child labor requirements of the Fair Labor Standards Act (FLSA) to skilled nursing care facilities, intermediate care facilities, and nursing and personal care facilities. It is designed to provide general information on the requirements of the FLSA and to alert employers to certain employment practices that result in FLSA violations.

Coverage : The FLSA covers all nursing care enterprises, public and private, whether operated for profit or not for profit.

Minimum Wage : FLSA covered employers are required to pay all nonexempt employees the Federal minimum wage of not less than $7.25 an hour effective July 24, 2009, on their regularly scheduled payday.

Overtime : Employers must also pay all non-exempt employees a rate of time-and-one-half the regular rate of pay for each hour of overtime worked. Nursing care facilities may pay employees overtime after 40 hours in a 7 day workweek or alternatively, use the "8 and 80" system. Under the "8 and 80" system, the nursing care facility may pay employees -- with whom they have a prior agreement -- overtime for any hours worked after more than 8 hours in a day and more than 80 hours in a 14-day period.

Recordkeeping : Employers are required to maintain accurate payroll and time records. Time records must be preserved for two years and payroll records must be kept for three years. Employers must also record and maintain the dates of birth for employees under age 19.

Exemptions : Certain employees whose primary duties are managerial, administrative, or professional in nature are exempt from the FLSA's minimum wage and overtime pay requirements.

Youth Employment : The FLSA sets a minimum age of 14 for most youth employed in covered non-agricultural employment. Fourteen- and 15-year-olds can work for limited periods of time each day (outside school hours) in specified occupations which do not interfere with their schooling, health, or well-being. Sixteen- and 17-year-old individuals may work at any time for unlimited hours in all jobs not declared hazardous by the Secretary of Labor.

Common Industry Problems

Non-exempt employees must be compensated for any time during which they perform activities that benefit the employer.

The most common violation in the nursing care industry is the failure of employers to pay for all the hours worked . This uncompensated time most frequently occurs when employers fail to pay for work performed:

• Before and after a worker's scheduled shift;
• During an employee's scheduled meal period; and
• While employees are attending staff meetings and compensable training sessions.

Minimum wage and overtime pay violations also occur when employers make deductions or demand reimbursement for the cost of required uniforms or equipment.

Individuals not otherwise employed by the facility who volunteer – without expectation of pay – to attend to the comfort of nursing home residents in a manner not otherwise provided by the facility are not considered employees under the FLSA. However, individuals (including residents) who perform work of any consequential economic benefit to the facility are employees and entitled to FLSA minimum wage and overtime .

Overtime pay violations often occur when employers:

• Fail to pay overtime after 8 hours of work in a day for workers (both full time and part time) who are under the "8 and 80" system.
• Pay overtime after 80 hours worked during a biweekly period rather than after 40 hours in a workweek to employees not under the "8 and 80" system.
• Fail to combine hours worked in more than one department or at more than one facility when determining the total overtime hours worked.
• Fail to include in calculating overtime hours the time spent or hours worked while performing on-call assignments.
• Fail to include shift differential, bonuses or on-call fees in calculating an employee's regular rate.
• Fail to pay overtime to non-exempt, salaried employees (e.g., clerical staff, cooks, and activities directors).

Other Pertinent Labor Laws

• The Immigration and Nationality Act, as amended by the Immigration Reform and Control Act requires employers to complete and maintain I-9 forms to verify the employment eligibility of all individuals hired after November 6, 1986, and contains certain anti-discrimination provisions.
• The Family and Medical Leave Act entitles eligible employees of covered employers to take up to 12 weeks of unpaid job-protected leave each year for specified family and medical reasons.
• The Employee Polygraph and Protection Act prohibits most employers from using any type of lie detector test either for pre-employment screening of job applicants or, with certain exceptions, during the course of employment.
• The Nursing Relief for Disadvantaged Areas Act of 1999 provides for the enforcement of employment conditions attested to by employers in disadvantaged areas employing H-1C temporary nonimmigrant registered nurses.
• The McNamara-O'Hara Service Contract Act requires the payment of prevailing wages and fringe benefits to service employees on contracts for the provision of services to the Federal government.

Where to Obtain Additional Information

For additional information, visit our Wage and Hour Division Website: http://www.dol.gov/agencies/whd and/or call our toll-free information and helpline, available 8 a.m. to 5 p.m. in your time zone, 1-866-4USWAGE (1-866-487-9243).

This publication is for general information and is not to be considered in the same light as official statements of position contained in the regulations.

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way. This document is intended only to provide clarity to the public regarding existing requirements under the law or agency policies.

An official website of the United States government

Here's how you know

Official websites use .gov A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

CMS Newsroom

Search cms.gov.

• Physician Fee Schedule
• Local Coverage Determination
• Medically Unlikely Edits
• Nursing Homes

Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities

Nursing home surveys are conducted in accordance with survey protocols and Federal requirements to determine whether a citation of non-compliance appropriate.  Consolidated Medicare and Medicaid requirements for participation (requirements) for Long Term Care (LTC) facilities (42 CFR part 483, subpart B) were first published in the Federal Register on February 2, 1989 (54 FR 5316). The requirements for participation were recently revised to reflect the substantial advances that have been made over the past several years in the theory and practice of service delivery and safety. The revisions were published in a final rule that became effective on November 28, 2016 .

The survey protocols and interpretive guidelines serve to clarify and/or explain the intent of the regulations. All surveyors are required to use them in assessing compliance with Federal requirements.  Deficiencies are based on violations of the regulations, which are to be based on observations of the nursing home’s performance or practices.

The items in the downloads section below provide additional information about the background and overview of the final rule, frequently asked questions, and other related resources.

Update: April, 2024

CMS consistently strives to improve the effectiveness and efficiency of our nursing home oversight and compliance programs to protect residents’ health and safety. In 2017, CMS implemented a new nursing home survey process across all states, in conjunction with the implementation of revised Requirements for Participation for Long Term Care Facilities.  Over the last few years, we have continued to improve the consistency, accuracy, and efficiency of the nursing home survey process. We believe it is important to prioritize limited resources toward those areas that pose an increased risk to individuals’ health and safety. By modifying some surveys based on compliance and quality history, we will be able to devote more time and resources to nursing homes with lower quality whose residents are at higher risk of harm. This effort to prioritize resources for nursing home surveys has become more pressing as the budget for survey and certification has remained flatlined at $397 million since 2015.   Please see the  President’s Budget for additional information about the President's proposals to shift funding for nursing home surveys from discretionary to mandatory and increase funding to cover 100 percent of statutorily-mandated surveys.

CMS is testing a risk-based survey (RBS) approach that allows consistently higher-quality facilities to receive a more focused survey that takes less time and resources than the traditional standard recertification survey, while ensuring compliance with health and safety standards. Higher quality could be indicated by a history of fewer citations for noncompliance, higher staffing, fewer hospitalizations, and other characteristics (e.g., no citations related to resident harm or abuse, no pending investigations for residents at immediate jeopardy for serious harm, compliance with staffing and data submission requirements). The number of nursing homes that could meet these criteria would be limited, such as up to 10 percent of nursing homes within a state . The survey resources saved by performing a more focused review of the required areas of a standard survey in these higher quality facilities would then be available to perform more timely oversight of facilities where the risks to residents’ health and safety are greater. If any concerns about resident safety were encountered during the RBS, it would immediately be expanded. Resident safety will always be prioritized, regardless of the type of survey process. The RBS process would not apply to complaint surveys.

CMS is working with states to test this process over the next several months. We will provide updates as we progress, and any official or formal memoranda will be posted to the CMS  website for Policy & Memos to States and CMS Locations .  

Exhibit 358 - 11.10.2022 (PDF)

Exhibit 359 - 11.10.2022 (PDF)

CMS-802 (PDF)

LTCSP Initial Pool Care Areas (ZIP)

Initial Surveys (ZIP)

LTCSP Interim Revisit Instructions - Updated 08/03/2018 (PDF)

Appendix PP State Operations Manual (Revised 02/03/2023) (PDF)

Revision History for LTC Survey Process Documents and Files Updated 4/1/2024 (PDF)

Survey Resources (ZIP)

Related Links

• Final Rule for Long Term Care
• Electronic Code of Federal Regulations
• Nursing Home Infection Preventionist Training
• MLN – Long Term Care Facilities

• Open access
• Published: 23 July 2024

Balancing act: exploring work-life balance among nursing home staff working long shifts

• Kari Ingstad   ORCID: orcid.org/0000-0003-4608-2294 1 &
• Gørill Haugan 1  

BMC Nursing volume  23 , Article number:  499 ( 2024 ) Cite this article

155 Accesses

Metrics details

Nursing home staff often face challenges in achieving a satisfactory work-life balance, particularly because of the nature of shift work. While long shifts offer extended periods off work, their impact on the delicate balance between work and leisure remains understudied in the context of nursing homes. This study investigated the experiences of nursing home staff in Norway working long shifts lasting 12–14 h and their perceptions of the balance between family life and work.

Eighteen nursing home staff members were interviewed following a semi-structured qualitative approach. The participants worked in three types of long shifts and provided insights into their experiences, addressing issues such as work hours, shift patterns, and work-family balance.

The study revealed four main categories: (1) impact of long shifts on family life—the highs and lows; (2) maximizing time off with long shifts; (3) reducing job stress with long shifts; and (4) full-time work leads to predictable hours and stable income. The participants emphasised the distinct separation between work and leisure during long shifts, acknowledging limited social life during working periods but appreciating extended periods off. Family life posed challenges, especially with young children, but the participants found benefits in the longer periods of family time during days off. Longer rest periods and reduced commuting time were perceived as advantages of long shifts, contributing to better sleep, reduced stress and overall well-being. Long shifts also allowed for more predictable working hours and income, supporting a stable work-life balance.

Balancing work and family life involves more than just the number of hours spent at work; it also encompasses the quality of those hours both at work and at home. Our findings underscore the complex interplay between work and family life for nursing home staff working long shifts. While challenges exist, benefits such as extended time off, improved sleep, reduced stress, and predictable working hours contribute positively to their work-life balance. Long shifts in nursing homes offer a unique perspective on achieving work-life balance, revealing both the challenges and advantages inherent in such schedules. Understanding the experiences of nursing home staff in this context can inform future innovations in shift scheduling, promoting a more balanced and sustainable work environment for healthcare professionals. For some healthcare staff, extended shifts can lead to a better work-life balance.

Peer Review reports

Introduction

Nursing home residents require round-the-clock care, necessitating shift work for staff. On the one hand, shift work may be perceived as flexible; for example, staff can work compressed hours and have longer periods of time off, or they can choose to work nights. On the other hand, shift work can be a negative experience because spare time that differs significantly from that of the majority may have limited social value [ 1 ]. A good work-life balance is important to health professionals’ health and quality of life (QOL). Therefore, shift work should be planned to facilitate a sound balance between work and leisure.

In Norway, day-work normally entails 37.5 h a week, while shift-work involves fewer working hours, varying from 33.6 to 35.5 depending on the amount of evening, night, and Sunday work. The Norwegian health system mostly includes timetables of day-, evening-, and weekend-shifts; several schedules also include night-shifts, while some positions only involve night-shifts. Nevertheless, only three per cent of registered nurses (RNs) in Norwegian hospitals work long shifts (12 h or more), while this figure is considerably higher in other comparable countries, such as Finland (8%) and Denmark (12%) [ 2 ]. In Norway, the most common working pattern for nurses is five 6–8-hour shifts and work every third weekend [ 3 , 4 ]. In regions beyond Scandinavia, the healthcare sector employs diverse shift schedules. While a three-shift pattern with two 8-hour day shifts and a night shift remains a common model, many countries, including Ireland, Poland, the USA, and increasingly, the UK, have adopted long shifts lasting 12 h or more as part of a two-shift system [ 5 , 6 ]. Shift systems can vary significantly across countries depending on shift length, rest periods, breaks, the number of consecutive shifts, whether the system follows a two-part or three-part rotation, and other such factors [ 7 , 8 , 9 ].

The organisation of shift schedules in Norwegian nursing homes has led to a significant number of health professionals working part-time. This results from the necessity to manage the staff rota, with many part-time employees needed to fulfil weekend staffing requirements. Among municipal healthcare staff working shifts in Norway, only 32 per cent work full-time [ 10 ]. Short shifts may contribute to a more stressful and hectic work experience [ 11 ]. A Dutch study indicated that individuals working more than 30–40 h a week experienced less stress than those working fewer hours [ 12 ]. Qualitative research must be conducted to examine the reason for this more closely.

Re-evaluating shift schedules must adhere to relevant laws and agreements. Most countries have such regulations [ 13 ]. In Norway, employees are required to have at least 11 h of continuous off-duty time within each 24-hour period, with work shifts followed by a daily rest period. Furthermore, employees must have at least 35 h of continuous off-duty time every seven days. Employers and employees` elected representatives in undertakings who are bound by a collective pay agreement may agree in writing to deviate from these requirements [ 14 ]. In Norway, an employee who has worked on a Sunday or a public holiday must have the following Sunday or public holiday off. However, employers and employees can agree in writing to a work schedule that ensures employees are off duty, on average, every other Sunday and public holiday over a 26-week period [ 14 ]. Furthermore, nursing personnel in Norway typically work a maximum of every third weekend. However, this arrangement is controversial as one-third of the staff who are scheduled to work cannot meet the staffing requirements for weekends, leading to a high reliance on temporary or part-time employees [ 15 ].

The optimal arrangement of shift schedules remains unclear [ 16 ]. Continuous innovation in shift organisation is necessary to maximise benefits for patients, employers, and employees. This study aimed to investigate the experiences of nursing home staff in Norway regarding the balance between family life and long shifts. Throughout the study, the term ‘long shifts’ refers to a working schedule based on shifts lasting 12–14 hours.

Work-life balance

Work-life balance can be defined as ‘the individual perception that work and non-work activities are compatible and promote growth in accordance with an individual’s current life priorities’ [ 17 ]. Achieving a healthier work-life balance not only enhances job satisfaction, performance, and commitment to the organization but also contributes to overall life and family satisfaction [ 18 ]. Furthermore, maintaining a balanced work-life dynamic is linked to lower levels of stress-related outcomes, including psychological distress, emotional exhaustion, anxiety, and depression [ 18 ]. A healthcare staff who works beyond the normal working day may find it particularly challenging to balance work and family obligations because they must be at work when kindergartens and schools are closed. However, working long shifts can reduce the impact of shift work on family and social life because longer shifts mean fewer days at work [ 9 ]. Studies on this are inconclusive. On the one hand, studies show that nurses often prefer long shifts as they improve work-life balance [ 19 , 20 ]. The extra days off are also often mentioned as the reason for a preference for long shifts [ 21 , 22 ]. However, work-life balance is also positively rated by nurses working 8-hour shifts [ 20 ].

Time is a limited resource for most families with children, who face competing demands on their time. However, perceptions of a good balance between work and family may differ among nurses. Whether this relationship is perceived as conflictual will be influenced by individual factors, macrostructures, and work organisation [ 8 , 22 ]. Many nurses care for children or ageing parents and provide wages and benefits critical to their families’ basic needs [ 22 ]. Exploring how the organisation of working hours can maintain work-life balance is important because this can reduce turnover and nurses’ intention to leave [ 23 ]. Exploring this within the municipality health service will be particularly significant because municipalities often lack the depth of professional expertise found in hospitals, and part-time employment is more prevalent in municipal settings than in hospitals across Norway [ 24 ]. As municipalities have assumed numerous responsibilities previously managed by hospitals, including handling a wide array of advanced and intricate tasks [ 25 ], ensuring optimal working conditions, and adhering to working time regulations can contribute to staff well-being and development. This, in turn, can facilitate retention within the services [ 26 ], which is crucial given the expected increase in the shortage of healthcare professionals in the years to come [ 24 ].

Most previous studies on the arrangements of nurses’ working hours and work-life balance have been conducted in hospitals [ 16 ]. To the authors’ knowledge, no such studies have been conducted in nursing homes. Hence, this study aimed to explore how nursing home staff experience balancing family life with working long shifts.

The study utilized a qualitative research design with a hermeneutic phenomenological approach to explore the lived experiences of nurses balancing family life while working long shifts. This approach guided the researchers to deeply engage with participants’ lived experiences and derive meaningful, contextually grounded interpretations [ 27 ]. The study included 18 individual semi-structured qualitative interviews. All the participants worked in nursing homes in three different types of long shifts. Two worked extremely long shifts: 14-hour shifts on seven consecutive days followed by two weeks off. Fourteen worked 12–14-hour shifts for 3–4 days with one week off between each work period. In these nursing homes, these were the only types of shifts available to the ward staff. Two of the participants worked long shifts every fourth weekend but otherwise worked 6–8-hour shifts. Among the informants, three did not have children, seven had children living at home aged 3 to 16, and eight had children who had moved out. Of those eight, seven regularly looked after their grandchildren. Table  1 presents participant characteristics.

Work in nursing homes encompasses a broad range of responsibilities, from providing practical assistance and psychological support to delivering advanced medical treatments, such as administering medication and wound care. Most patients are elderly individuals with various chronic illnesses, disabilities, or frailties, and many suffer from dementia. Both RN and assistant nurses in Norwegian nursing homes address patients’ basic needs, including personal hygiene and nutrition. Furthermore, RN handle medications safely, monitor their effects, and have the authority to administer certain medications independently. Additionally, both registered and assistant nurses in Norway often perform tasks that do not necessarily require their level of education but are well within the competence of the assistants [ 26 ].

Sample and procedure

Strategic sampling was employed to ensure that participants could shed light on the research question. Inclusion criteria were that participants worked in a nursing home with shifts of at least 12 h. The first author gathered information from the media and employee organisations about nursing homes that use long shifts. The managers of these nursing homes were contacted and asked to pass on letters to potential participants working long shifts; they were asked to find a broad sample of participants in terms of age, sex, and attitude. The participants were contacted by phone one week after receiving a written invitation. Eighteen participants were contacted, and they all attended the interview. They worked in four nursing homes in four different counties. The interviews took place at the nursing homes where they worked. Based on previous research in the field, an interview guide was prepared for the interviews. The interview guide was developed specifically for this study, including topics such as working hours, shift patterns, perceived workloads, and work-family balance. The study interview guide is provided as supplementary file 1.

The analysis draws on Kvale’s approach to phenomenological hermeneutic analysis, which is characterized by a systematic and reflexive process that integrates a deep understanding of participants’ experiences with ongoing interpretation and critical reflection [ 28 ]. This involved a dialectical movement between the parts and the whole, employing a continuous back-and-forth process based on the hermeneutic circle to achieve progressively deeper insights into meaning [ 27 , 28 ]. Our comprehension evolved throughout the interviews, data processing, and dissemination processes. Specifically, during the interviews and transcription process, analytical and theoretical ideas, as well as noteworthy statements, were frequently noted. The initial examination of the text provided a description of the staff’s experiences of working long shifts, offering a preliminary interpretation. Subsequent in-depth analyses yielded a more profound understanding of the text’s content. For example, we gained insight into how employees’ experiences of long shifts facilitated a clearer separation between work and private life. Particularly, long shifts provided longer continuous periods of time off, making it easier to fully disconnect during this time. This reflects what Gadamer described as reaching a new horizon [ 27 ]. Meaning categorisation was employed as an analytical tool, generating categories and sub-categories during the analysis [ 28 ] (see Table  2 ). Based on the interviews and the interpretations derived from them, key attributes of the studied phenomenon were identified, which allowed us to capture nursing home staff’s experiences of balancing family life and work while working 12–14 h shifts. Throughout the analysis, the categories were changed, abstracted, and adapted to the data. The coding process aimed to reduce the amount of data and gain a clearer idea of the topics emphasised by the participants.

The possible consequences of an interview study should be assessed in terms of harm to the interviewees [ 28 ]. Participation was voluntary, and participants could withdraw at any time. All participants provided written consent. Little sensitive information emerged during the interviews, and none of the participants withdrew. The participants were happy to contribute to a research project that shed light on their experiences of working long shifts.

Trustworthiness

Ensuring the trustworthiness of qualitative studies involves maintaining credibility, dependability, confirmability, and data transferability [ 29 ]. In this study, the authors’ experiences as nurses and familiarity with the context bolstered trust and enriched data collection. Continual review and detailed analysis ensured data dependability, aligning the findings with raw data to enhance reliability. To ensure confirmability, the study described participants’ experiences in detail, thereby making the findings meaningful and transferable. The researchers relied heavily on raw data during analysis to prevent data loss and validated the findings by referencing supporting research while addressing conflicting evidence.

A work schedule of long shifts entails employees working for many consecutive hours, with extended periods of time off between each work period. The duration of time off is linked to the length of the shifts and the number of consecutive shifts worked. Employees with many consecutive long shifts will enjoy more extended periods of time off. This study delineates how long shifts may impact staff experiences of balancing work and leisure. The findings are presented in four categories:

Impact of long shifts on family life—the highs and lows.

Maximizing time off with long shifts.

Reducing job stress with long shifts.

Full-time work leading to predictable hours and stable income.

Impact of long shifts on family life—the highs and lows

Working a 12-hour shift means that much of one’s waking hours are spent at work. Long workdays, combined with extended time off, create a distinction between work and leisure. This approach has clear advantages, but it also comes with certain challenges. In particular, someone who works long shifts has considerably less time and energy for other activities during work periods. In this study, two participants described how working long shifts affected their social life during these times:

You’re totally antisocial the week you work, it’s just work and sleep, that’s all you have time for. (5) The four days you’re at work you don’t have much in terms of privacy. (4)

Long shifts can pose challenges because children’s schedules often do not align with such extended work hours. Both kindergartens and schools typically close at 4 or 5 pm. Consequently, parents working long shifts may encounter difficulties harmonising this schedule with family life. However, family situations and obligations vary, including different family constellations. Parents of young children may require assistance in picking up their children from kindergarten and school and taking care of them throughout the evening. Furthermore, this implies that during working periods, parents may have limited time with their children. The advantage lies in the longer periods off, allowing for ample family time:

If you’ve got a family, you don’t see your children for four days, they’ve gone to bed when you get home, and you only see them briefly in the mornings. But it’s the same when you work normal shifts, you have late shifts then too, and parents with children in kindergarten and school can’t pick them up and then go on a late shift, you must have someone else to pick them up. (4) I fully understand my work situation, how we share the housework and so on. So, for us, it works fine. But I notice that our youngest boy isn’t happy when I start work, because then I’ll be away so much. But when we talk about it and say that I’ll have a whole week off, then he says yes, because that means so much. Then things are ok. (16)

The need for babysitting in the evenings and on weekends is a common requirement for anyone with children working shifts, regardless of the shift-work organisation. However, being away from one’s family almost the entire day for several days poses a specific challenge associated with long shifts, necessitating others to willingly care for the children during working periods. However, long shifts also offer extended periods of leisure time, providing opportunities for activities that may be impractical with traditional shift-work. Some participants believed that the benefits outweigh the disadvantages. Having several consecutive days off allows for travel, caring for grandchildren, hiking, and complete relaxation. The extended periods of free time were highlighted as a particularly positive aspect of working long shifts:

If we must go back to traditional shifts, I think I might retire. Because this shift really suits me. I can travel, I love travelling. I can look after my grandchildren, and I have time to arrange things if there’s something special. (2)

Long shifts encompass intensive work periods and extended periods of time off, which are distributed systematically throughout the year. Compressed work periods can be an advantage at times, but if they coincide with public holidays, nurses naturally find it annoying. As one participant explained:

That’s the worst thing, this year my shift falls on the 23rd of December, Christmas Eve, and Christmas Day, and that’s not much fun. But last year it was another team that had Christmas, and then I had time off until New Year’s Day, so this year it’s our turn. (10)

Some periods away from the family are worse than others. If work periods coincide with Christmas or Easter, it can be particularly frustrating to work long shifts because one must be at work all day for several days while most other people spend time off celebrating the holidays.

Maximizing time off with long shifts

Long shifts mean intense work periods. The total of 35.5 h per week is completed in under five days. Consequently, staff who work long shifts have longer periods of time off than those who work traditional shifts. Longer time off means more possibilities and flexibility. One participant said:

I have so much spare time… I can go for walks in the mountains, I can study. (1)

With regular shifts lasting 7–8 h, having only 1–2 days off in a row is common. Simultaneously, when the work involves significant caring responsibility and emotional strain, many people may think about their job even after the shift is over. Longer shifts result in longer continuous periods of time off, allowing for a greater degree of disconnection from work.

I used to feel like I was at work all the time, you did day shift, evening shift, evening shift, day shift. You had one day off before the weekend and one day after. That wasn’t so good for me. Now I’m so happy with this arrangement, you can’t imagine. You can plan a lot more, I can travel, you can do so many things. I couldn’t do those things when I was doing day and evening shifts. (3)

For healthcare professionals working long shifts, the length of time off depends on the shift duration and the consecutive shifts worked. Typically, they can enjoy 3–8 days off consecutively. Extended periods of time off facilitate detachment from work, allowing for complete relaxation. In other words, the scheduling of long shifts facilitates detachment from work during off periods, suggesting reduced stress and improved recovery during leisure time.

Reduced job stress with long shifts

With 12-hour shifts, work can be organized differently than with traditional 7–8-hour shifts. The extended duration allows for more consecutive hours at work, facilitating innovative ways of task allocation. Contrastingly, 8-hour shifts impose tighter time constraints for completing tasks before the next shift commences in the evening. However, the flexibility of 12-hour shifts permits task distribution in new and creative ways, potentially reducing stress levels. Additionally, long shifts ensure work continuity throughout the day, enhancing workflow efficiency. Two participants described it as follows:

I have a clear view of my patients from morning to evening. (8) There’s less stress with long shifts. If it’s showering, wound care, or similar tasks, we can do them in the afternoon if the morning is busy. (2)

Twelve-hour shifts involve two handovers per day instead of the usual three in traditional shift schedules. With fewer shifts, less time is spent changing shifts, ensuring greater continuity throughout the day and longer intervals between shifts. When shifts are 12–14 h long, there will be at least 10–12 h between each shift, which helps mitigate the challenges of quick returns. The participants highlighted the longer rest periods between shifts as an advantage of long shifts:

You used to have more changing from late shift to early shift, then you finished at quarter past ten and had to be back here at 7.30 the next morning, which made me sleep worse at night. Now when I get home at half past eight, I have a lot of the evening left so I can relax before I go to bed, and then I sleep better. So, it also means you’re not so tired. When you get home you can sink into a comfortable chair and watch some TV, but when you get home at half past ten and you know you have to get up at half past five, you just think you must hurry up and get to sleep. In fact, I’m not more tired now. (10) It was a bit too much stress to finish at a quarter past ten when you had to be back at work again at half past seven. It was more stressful to sleep then than it is now. (9)

Short rest periods between shifts can cause stress owing to worries about getting enough sleep. Some of this stress can be avoided with long shifts because of the longer time to rest and sleep between shifts. The length of shifts also affects the number of days at work and time spent commuting. Long shifts involve fewer days at work than traditional shifts:

I couldn’t stand it if I had to do two shifts in the usual way, because I have an hour’s drive to get to work, and then I’d come here and work seven hours, then I’d drive home and be at home just a few hours before I went back to work for seven more hours. No, I couldn’t stand that, it would be too hard on me. (3)

Long shifts mean reduced time spent commuting. Hence, long shifts are advantageous to those travelling from afar; less time spent commuting means more free time.

The participants perceived that compressed working hours, coupled with longer periods off, facilitated a clearer work-life separation compared with traditional 6–8-hour shifts. Social life during the working period was extremely limited. In this manner, participants working long shifts experienced a distinct separation between work and leisure:

I have so much spare time, and when I’m at home I don’t have to think about things at work. That’s the best part of it. I can more easily separate work and time off. I’m not always at work, and when I’m at home I can do other things. (1) You have less stress with a schedule like that. When you’re at work, you’re at work, and when you’re at home you have time off. Your stress level goes down. (4)

A clear distinction between work and leisure time may have both advantages and disadvantages. On the one hand, it fosters uninterrupted continuity during work hours. On the other hand, it results in extended periods of time off, leading to breaks in continuity. For instance, nurses may go more than a week without seeing a patient, necessitating significant catch-up upon return to work.

I feel like I’ve lost track of things after a week off. That’s why we’ve started implementing this one-day overlap. (9)

This discontinuity can pose challenges, particularly for employees working in fixed teams. However, implementing overlap periods between teams, where employees from different shifts coincide, can mitigate this issue.

Full-time work leads to predictable hours and stable income

6–8-hour shifts and work every third weekend represent the traditional scheme in Norway, causing many employees to work part-time. In contrast, long shifts make it possible to work in only one ward, supporting continuity and thereby enhancing patient safety while facilitating a stable and positive working environment. Moreover, long shifts encourage staff to take on larger percentages of full-time positions. Consequently, working full-time or almost full-time provides predictable working hours and a reliable income, contributing to a more stable situation both financially and socially:

If I can’t carry on in this kind of shift work, I’ll have to go back to a 60% job. And then I don’t know if I want to continue. Because then I’ll have that hectic life with short shifts and a lot of driving and never any free time. Because then I’d have to start doing more work to make ends meet and have ok finances. (3) I used to work on three wards to reach a full-time position, but now I feel a sense of belonging to this ward. I feel more self-confident, I feel that I know this field for this group of patients. (7)

Several participants, particularly assistant nurses, increased their full-time job percentage after changing to long shifts, and all of them had at least a 70 per cent position. A high percentage makes it easier to understand when to go to work and when to take time off. It also ensures a predictable income, eliminating the need to be on the lookout for extra shifts to make ends meet. Furthermore, the participants were pleased that they now only worked in one ward. Having a high percentage of a full-time position in a single ward provides continuity, greater professional confidence, improved collaboration, a sense of belonging, and overall well-being—all factors known to support patient security.

The association between work and family life is frequently examined through the lens of work-life balance or work-life integration [ 30 ]. Work-family balance entails aligning work and non-work activities to support personal growth in line with an individual’s current life priorities [ 17 ]. It transcends mere job satisfaction, influencing overall life and family contentment while also reducing stress-related outcomes [ 18 ]. Thus, work-life balance is not solely dependent on the number of hours spent at work; it also encompasses how individuals feel both during work hours and when they are off duty.

Maintaining a balance between work and leisure poses particular challenges, especially for healthcare professionals working in shifts [ 8 , 23 , 31 ]. Patients require round-the-clock care, necessitating staff to work during hours when schools and kindergartens are closed and when others typically have time off. Hence, for individuals working outside conventional working hours, designing shifts that optimize work-life balance for as many staff members as possible is crucial. Moreover, laws and agreements must prioritise both patients’ needs and those of employees for work-life balance. In Norway, debate is ongoing about whether existing regulations adequately address this issue, given that current mandates, such as working only every third weekend, result in numerous part-time positions [ 26 ]. A proposed solution for increasing full-time employment is the adoption of long shifts [ 32 ]. However, whether long shifts can effectively enhance work-life balance remains uncertain. The present study explored the firsthand experiences of nursing home staff engaged in long shifts, specifically focusing on how they navigate the balance between work responsibilities and personal time.

The results showed that working long shifts supports a clearer separation between work and leisure time compared with the ‘normal’ working schedule. During working periods, nurses’ focus is on work, while during non-working periods they have plenty of time to relax and do other things. Long shifts involve compressed working hours accompanied by a considerably limited social life along with little time to spend with children and other family members. Children may be unhappy about hardly seeing their parent for several days. Furthermore, when one’s work periods coincide with Easter, Christmas, and other public holidays, working can be tiresome and make one feel that one is losing out. Nevertheless, the participants in this study felt that these disadvantages were outweighed by the advantages of working long shifts. Long shifts provide extended periods of time off, allowing healthcare professionals to pursue leisure activities, spend time with family, or engage in hobbies. This flexibility can enhance overall well-being, which is not always possible with traditional shifts. Long shifts include a longer break of 10–12 h between shifts supporting better sleep and recovery, whereas the traditional shift schedule may provide only 8–9 h between evening and day shifts, causing more stress and insomnia. The participants underlined the benefit of having a longer period between finishing work in the evening and leaving for work in the morning; the extra time made it easier to relax and calm down after the first shift and resulted in better sleep. ‘Quick returns’, involving a short break between evening and day shifts, are more common in Norway than in other countries. In the Norwegian context, as many as 64 per cent of hospital nurses have more than 13 evening-to-day shift transitions per year, while in Finland the figure is 47 per cent and in Denmark 16 per cent [ 2 ]. Such quick returns can worsen the work-life balance [ 33 ] and cause more stress. This is considerably less of a problem with long shifts because of the longer time off between the shifts.

Some participants saw it as an advantage that long shifts mean less time spent commuting because of fewer days at work. Long shifts of 12.5 h result in 133 days at work per year, and 232 days off. Shifts of 7.5 h will mean 222 days at work and 143 days off, while six-hour shifts will involve 277 days at work and 88 days off (see Table  3 ). Fewer days at work lead to less commuting time and will be particularly helpful for staff with a long journey between home and work.

Balancing work and family life also implies predictable working hours and pay.

In municipal health and care services in Norway, 57% of nurses are employed on a full-time basis, and 28.5% of assistant nurses follow suit [ 24 ]. One might expect that part-time work makes it easier to combine work and family/leisure time. However, studies show that this is not necessarily the case. Healthcare workers in part-time jobs report an equal or greater degree of work-family conflict than those working full-time [ 12 , 31 ]. The way work is organised seems to be more important for a good work-life balance than whether one works part-time [ 31 , 34 ]. This may partly be because many part-time staff work more than their fixed hours, that is, they work extra shifts to get a living wage. Moreover, on days which basically are ‘my-day-off’, they must be willing to work, often at short notice. Part-time workers may be considered ‘second-class workers’ who are subject to stress and strain in the form of inconvenient shifts, lack of control, and no clear work schedule [ 31 , 35 , 36 ]. Working part-time can result from the employer’s need for part-time employees as much as the employee’s preference for part-time work [ 37 ].

A part-time job along with a search for extra shifts means an unreliable income and unpredictable working hours and time off [ 3 , 36 ]. Lack of control over one’s working hours causes stress and is an additional work-related burden [ 38 ]. This study highlights that long shifts, particularly for assistant nurses, offer positions that are (almost) full-time, with more predictable working hours and income. Other studies have shown that long shifts are a way of organising work that gives employees more predictable working hours, leisure, income [ 32 ], and a better balance between work and family life than ordinary shifts [ 9 , 39 ]. Many employees enjoy shift-work; evidence shows that those who work long shifts and jointly planned shifts (where staff have a say in their shifts) express the greatest satisfaction with shift-work [ 39 ].

Shifts are not solely about meeting employees’ preferences and requirements; they are equally important for maintaining high-quality services for patients. This study explored the experiences of employees. It highlighted that increased full-time positions and staff continuity during long shifts offer greater flexibility and reduce job stress throughout the working day, facilitating efficient handling of necessary tasks. However, extended periods off work can disrupt this continuity, suggesting the need to implement overlap periods between teams to ensure uninterrupted service continuity. Additionally, when nurses work long shifts with extended time off, it may affect their ability to supervise students. If the students are not working long shifts themselves, it becomes challenging to provide adequate follow-up when nurses have extended time away from work.

Working hours consist of several dimensions: structural, quantitative, and qualitative. Important factors may be the length of shifts, working hours per week, opportunity to take breaks, shift rotation, working environment, self-perceived competence, well-being, control, and work intensity [ 8 ]. Working hours represent both a key economic and cultural category, as well as a social category. The notion of balance has been criticised because it assumes that individuals should achieve an appropriate distribution of hours between work, family, and leisure [ 40 ]. A related concept is work-family conflict, which refers to difficulty in combining work and family roles [ 41 ]. The term ‘work-family conflict’ seems useful since staff experiences of combining family and employee roles are fundamental. This study has shown that staff who work long shifts experience a conflict between work and family but still find more advantages than disadvantages to this type of shift schedule. For example, many employees prefer not to work over weekends. Nevertheless, this is mostly impossible to avoid in the health sector, as patients also need care and treatment at weekends. Within a long shift schedule, staff not only work more hours at weekends during their compressed work periods but also have more weekends off [ 11 ]. Employees working longer shifts on weekends benefit from more weekends off. When employees are satisfied with this arrangement, it highlights that work-family balance is influenced not only by the number of hours worked but also by how those hours are organized.

New generations of employees often want to participate fully in the working life, which calls for employers to draw up shift schedules that are adapted to a culture of full-time work [ 36 ]. The current lack of health professionals indicates a need for fundamental changes to the shift schedule to make it compatible with full-time jobs, which allow a predictable salary and work-life balance. Efforts to create a sustainable shift rotation system based on full-time positions must enable a balanced rhythm between recovery and work [ 36 , 42 ].

Strengths and limitations

Long shifts are uncommon in nursing homes across Norway, with only a few establishments adopting this system. Consequently, qualitative in-depth interviews serve as a suitable method for understanding how employees perceive the impact of long shifts on their work-life balance. However, considering the limited availability of long shifts, relatively few healthcare workers have the opportunity to experience them. All the participants in this study willingly applied for positions involving long shifts, despite having the option to opt for departments with traditional shifts. In this regard, had these employees been compelled to work such shifts, additional insights into long shifts could have been obtained.

Balancing work and family life isn’t just about the number of hours spent at work; it’s also about the quality of those hours both at work and at home. Whether working long or short shifts, the total hours may be the same, but long shifts can feel less stressful while on duty. Additionally, longer consecutive periods of time off, as seen with long shifts, provide a different experience compared to having more daily time off with short shifts. This study contributes new insights into how nursing home employees experience work-family balance when working long shifts. The findings indicate that long shifts better separate work and leisure than traditional shifts. During working periods, social life and hobbies are significantly limited, providing little time for children and other family members. One’s entire focus is on work during these periods. However, during the off-work period, one can relax and do completely different things without thinking about work. Some participants considered this a good way of organising their work-life, providing a better balance between work and leisure. Long shifts result in less time spent commuting because fewer days are spent at work and eliminate quick returns, as the rest period from finishing work in the evening until starting again in the morning is longer. Furthermore, long shifts provide staff with more full-time or almost full-time jobs, which provide predictable pay, working hours, and leisure time. Healthcare workers may have different wishes and needs, and their family situation will vary. Similarly, the extent to which long shifts improve employees’ work-life balance will vary. Nonetheless, this study showed that long shifts enable a clearer separation of work and leisure, followed by less stress, better sleep, and recovery. Logically, reduced stress and enhanced continuity in patient care are positive side effects of long shifts. Balancing work and leisure can be particularly challenging for shift workers, making it important to draw up shift schedules that provide the best possible work-life balance.

Data availability

The data will be available from the corresponding author on request.

Ogeill RP, Savic M, Ferguson N, Lubman DI. Shift-Work-Play: understanding the positive and negative experiences of male and female shift workers to inform opportunities for intervention to improve health and wellbeing. AJAN. 2021;38:23–33.

Article   Google Scholar  

Garde AH, Harris A, Vedaa Ø, Bjorvatn B, Hansen J, Hansen ÅM, et al. Working hour characteristics and schedules among nurses in three nordic countries – A comparative study using payroll data. BMC Nurs. 2019;18:12.

Article   PubMed   PubMed Central   Google Scholar  

Ingstad K. Turnus Som fremmer heltidskultur. Oslo. Gyldendal Akademisk; 2016.

Ose SO, Tjønnås MS, Kaspersen SL, Færevik H. One-year trial of 12-hour shifts in a non-intensive care unit and an intensive care unit in a public hospital: a qualitative study of 24 nurses’ experiences. BMJ Open. 2019;019:e024292. https://doi.org/10.1136/bmjopen-2018-02429 .

Ball J, Day T, Murrells T, Dall’Ora C, Rafferty AM, Griffiths P, et al. Cross-sectional examination of the association between shift length and hospital nurses job satisfaction and nurse reported quality measures. BMC Nurs. 2017;16(1):26. https://doi.org/10.1186/s12912-017-0221-7 .

Griffiths P, Dall’Ora C, Sinden N, Jones J. Association between 12-hr shifts and nursing resource use in an acute hospital: longitudinal study. J Nurs Manag. 2019;27(3):502–8. https://doi.org/10.1111/jonm.1270 .

Article   PubMed   Google Scholar  

Bae SH, Fabry D. Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: systematic literature review. Nurs Outlook. 2014;62:138–56.

Dall’Ora C, Ball J, Recio-Saucedo A, Griffiths P. Characteristics of shift work and their impact on employee performance and wellbeing: a literature review. Int J Nurs Stud. 2016;57:12–27.

Harris R, Sims S, Parr J, Davies N. Impact of 12 h shift patterns in nursing: a scoping review. Int J Nurs Stud. 2015;52:605–34.

KS. [Central Association of Municipalities]. Heltids-/deltidsstatistikk; 2023. https://www.ks.no/fagomrader/statistikk-og-analyse/statistikkpakken/statistikkpakken2/ .

Ingstad K, Amble N. En Ny Ro med langturnus. Nord J Nurs Res. 2015;35:152–7.

de Veer AJE, Francke AL, Struijs A, Willems DL. Determinants of moral distress in daily nursing practice: a cross sectional correlational questionnaire survey. Int J Nurs Stud. 2013;50:100–8.

Working hours. Your Europe. 2024. https://europa.eu/youreurope/business/human-resources/working-hours-holiday-leave/working-hours/index_en.htm .

Act relating to the working environment, working hours and employment protection, etc. (Working Environment Act) - Chap. 10. Working hours. Lovdata. 2024. https://lovdata.no/dokument/NLE/lov/2005-06-17-62/KAPITTEL_11#%C2%A710-6 .

Strengthening health systems through nursing. Evidence from 14 European countries. In: Rafferty AM, Busse R, Zander-Jentsch B, Bruyneel L, Sermeus W, editors. Copenhagen (Denmark). European Observatory on Health Systems and Policies; 2019.

Ejebu OZ, Dall’Ora C, Griffiths P. Nurses’ experiences and preferences around shift patterns: a scoping review. PLoS ONE. 2021;16:e0256300.

Article   PubMed   PubMed Central   CAS   Google Scholar  

Kalliath T, Brough P. Work–life balance: a review of the meaning of the balance construct. J Manag Organ. 2008;14:323–7.

Sirgy MJ, Lee DJ. Work-life balance: an integrative review. Appl Res Qual Life. 2018;13(1):229–54. https://doi.org/10.1007/s11482-017-9509-8 .

Day G. Is there a relationship between 12-hour shifts and job satisfaction in nurses. Alabama State Nurses’ Association. 2004;31(2):11–2.

Google Scholar  

Haller T, Quatrara B, Miller-Davis C, Noguera A, Pannone A, Keim-Malpass J, et al. Exploring perceptions of shift length: a state-based survey of RNs. J Nurs Adm. 2020;50(9):449–55. https://doi.org/10.1097/nna.0000000000000915 .

Baillie L, Thomas N. Changing from 12-hr to 8-hr day shifts: a qualitative exploration of effects on organising nursing care and staffing. J Clin Nurs. 2019;28(1–2):148–58. https://doi.org/10.1111/jocn.14674 .

Mullen K. Barriers to work–life balance for hospital nurses. Workplace Health Saf. 2015;63:96–9. https://doi.org/10.1177/2165079914565355 .

Matsuo M, Suzuki E, Takayama Y, Shibata S, Sato K. Influence of striving for work–life balance and sense of coherence on intention to leave among nurses: a 6-month prospective survey. Inquiry. 2021;58:1–9.

Jia Z, Kornstad T, Stølen NM, Hjemås G. Arbeidsmarkedet for helsepersonell fram mot 2040. [Oslo]: Statistisk sentralbyrå; 2023.

Rohde T, Grut L, Lippestad J, Anthun K. Samhandling mellom kommuner og sykehus. Volume 13. Oslo: SINTEF Digital Rapport; 2020 May.

NOU. Tid for handling. Personellet i en bærekraftig helse-og omsorgstjeneste. (2023). https://www.regjeringen.no/contentassets/337fef958f2148bebd326f0749a1213d/no/pdfs/nou202320230004000dddpdfs.pdf .

Gadamer HG. Truth and method. London: Sheed & Ward; 1989.

Kvale S, Brinkmann S. Det kvalitative forskningsintervju. Oslo: Gyldendal Akademisk; 2015.

Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park, CA: Sage; 1985.

Book   Google Scholar  

Kumar S, Sarkar S, Chahar B. A systematic review of work-life integration and role of flexible work arrangements. Int J Organ Anal. 2023;31:710–36.

Abrahamsen B, Holte KA, Laine M. Work-family interference: nurses in Norway and Finland. Prof Prof. 2012;2:60–75.

Moland LE, Tofteng M, Bråthen K. Hva koster heltid egentlig? Fafo-rapport 2023:22.

Shiffer D, Minonzio M, Dipaola F, Bertola M, Zamuner AR, Dalla Vecchia LA, et al. Effects of clockwise and counterclockwise job shift work rotation on sleep and work-life balance on hospital nurses. Int J Environ Res Public Health. 2018;15:2038.

Holland P, Tham TL, Sheehan C, Cooper B. The impact of perceived workload on nurse satisfaction with work-life balance and intention to leave the occupation. Appl Nurs Res. 2019;49:70–6.

Ingstad K, Kvande E. Må Sykepleieryrket være et deltidsyrke? Nordisk Sygeplejeforskning. 2011;1:206–18.

Vabø M, Drange I, Amble N. Den Vanskelige Deltidsknuten – En særnorsk utfordring som rammer unge helsefagarbeidere. Fagbladet. https://fagbladet.no/mapper/dokumenter/Deltidsknuten_siste.pdf . 2019.

Ingstad K, Hedlund M. Part-time or full-time employment: choices and constraints. Nordic J Working life Stud. 2017;7:73–89.

Hsu YY, Bai CH, Yang CM, Huang YC, Lin TT, Lin CH. Long hours’ effects on work-life balance and satisfaction. BioMed Res Int. 2019;2019:5046934. https://doi.org/10.1155/2019/5046934 .

Moland LE, Bråthen K. Resultater fra forprosjektering i åtte kommuner og en landsdekkende undersøkelse. En: ny vei mot heltidskultur Fafo-Rapport. 2019;2019:15.

Ellingsæter AL. Vår tids moderne tider. Oslo: Universitetsforlaget; 2009.

Greenhaus JH, Beutell NJ. Sources of conflict between work and family roles. Acad Manag Rev. 1985;10:76–88.

Amble N. 3-3-Turnus. IN: Ingstad, K. (red). Turnus som fremmer heltidskultur. Oslo: Gyldendal Akademisk; 2016.

Download references

Acknowledgements

Not applicable.

No funding.

Open access funding provided by Nord University

Author information

Authors and affiliations.

Faculty of Nursing and Health Science, Nord University, Pb. 93, Levanger, 7601, Norway

Kari Ingstad & Gørill Haugan

You can also search for this author in PubMed   Google Scholar

Contributions

KI collected the data, framed and initiated the analysis, and led the drafting of the manuscript. GH contributed to writing and editing the manuscript. Both authors approved the final version to be published.

Corresponding author

Correspondence to Kari Ingstad .

Ethics declarations

Ethics approval and consent to participate.

This study was reviewed by the Norwegian Centre for Research Data, NSD (no. 35126). In accordance with Norwegian law governing medical and health research, ethical approval from an ethics committee was not required for the current research context, as the study did not meet the criteria for health research, and no health-related data were collected. The study adhered to the principles outlined in the Declaration of Helsinki. Participants were assured that participation in this study was voluntary and anonymous, and that all data were confidential and accessed only by members of the research team. Finally, all participants provided written informed consent.

Consent for publication

Competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Ingstad, K., Haugan, G. Balancing act: exploring work-life balance among nursing home staff working long shifts. BMC Nurs 23 , 499 (2024). https://doi.org/10.1186/s12912-024-02165-8

Download citation

Received : 29 February 2024

Accepted : 10 July 2024

Published : 23 July 2024

DOI : https://doi.org/10.1186/s12912-024-02165-8

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Long shifts
• Nursing home staff
• Healthcare professionals
• Nursing homes
• Family life
• Shift schedules
• Job satisfaction
• Work-life conflict

BMC Nursing

ISSN: 1472-6955

• General enquiries: [email protected]

Job Posting: Registered Nurse

Department of Veterans Affairs

$9,233.00 - $11,005.00 per Month

Final Filing Date: 8/11/2024

Job Description and Duties

This is an exciting opportunity to join our team at the California Department of Veterans Affairs (CalVet), where we proudly serve California’s 1.6 million veterans. We advocate with purpose and passion every day for our state’s veterans and their families and connect them to their earned benefits. We offer a range of services, from our network of award-winning veterans' homes to our innovative home loans program. Additionally, we provide special statewide benefits and veteran outreach services.

CalVet provides our staff with a wide range of fulfilling and enriching growth opportunities in skilled trades, healthcare, administrative and professional fields, and beyond. We actively cultivate an inclusive atmosphere that embraces individuals from diverse backgrounds, cultures, and life journeys, empowering them to excel and flourish. We enthusiastically welcome your distinctive contributions to our organization and the meaningful work we undertake.

Apply today to join our team! We especially encourage veterans to apply utilizing the state’s  Veterans Preference program . Visit our website at  www.calvet.ca.gov  to learn more about us.

This position is located in Nursing Services at the Veterans Home of California, Yountville.

These positions are subject to the Post and Bid requirements for Bargaining Unit 17.

Please note: You will need to take and pass an examination for Registered Nurse to establish list eligibility prior to job offer.  Please follow link for exam:  Exam code=2368

Pleasevisit  https://www.jobs.ca.gov/CalHRPublic/Landing/Jobs/Steps.aspx for more information.

You will find additional information about the job in the Duty Statement .

Working Conditions

Working overtime is a requirement of this position.

Employees of CalVet will be required to follow state or county public health guidelines and requirements enacted in accordance with infectious disease prevention and control.

Minimum Requirements

• REGISTERED NURSE (MAND)

Additional Documents

• Job Application Package Checklist
• Duty Statement

Position Details

Department information.

The California Department of Veterans Affairs (CalVet) works to serve California veterans and their families. With nearly 2 million veterans living in the State, CalVet strives to ensure that its veterans of every era and their families get the state and federal benefits and services they have earned and deserve as a result of selfless and honorable military service. CalVet strives to serve veterans and their families with dignity and compassion and to help them achieve their highest quality of life.

Per Military and Veterans Code, Section 80, whenever possible, preference shall be given to veterans for employment in the Department of Veterans Affairs.

Special Requirements

• The position(s) require(s) a(n) California Board of Registered Nurses License. You will be required to provide a copy of your license prior to being hired.

Successful completion of a live scan and a pre-employment physical (including drug testing for certain civil service classifications) will be required.

Application Instructions

Completed applications and all required documents must be received or postmarked by the Final Filing Date in order to be considered. Dates printed on Mobile Bar Codes, such as the Quick Response (QR) Codes available at the USPS, are not considered Postmark dates for the purpose of determining timely filing of an application.

Who May Apply

How To Apply

Address for Mailing Application Packages

You may submit your application and any applicable or required documents to:

Address for Drop-Off Application Packages

You may drop off your application and any applicable or required documents at:

Required Application Package Documents

The following items are required to be submitted with your application. Applicants who do not submit the required items timely may not be considered for this job:

• Current version of the State Examination/Employment Application STD Form 678 (when not applying electronically), or the Electronic State Employment Application through your Applicant Account at www.CalCareers.ca.gov. All Experience and Education relating to the Minimum Qualifications listed on the Classification Specification should be included to demonstrate how you meet the Minimum Qualifications for the position.
• Resume is required and must be included.

The website below is intended to provide general information. Benefit eligibility may be based on job classification, bargaining unit, time base and length of appointment. Additional benefits may also be outlined for specific bargaining units in employee collective bargaining contracts. Please review this information prior to accepting employment. https://www.calhr.ca.gov/Pages/California-State-Civil-Service-Employee-Benefits-Summary.aspx

Contact Information

The Human Resources Contact is available to answer questions regarding the application process. The Hiring Unit Contact is available to answer questions regarding the position.

Please direct requests for Reasonable Accommodations to the interview scheduler at the time the interview is being scheduled. You may direct any additional questions regarding Reasonable Accommodations or Equal Employment Opportunity for this position(s) to the Department's EEO Office.

ADDITIONAL INSTRUCTIONS

If mailing or dropping off your State Application (STD. 678) please note position #573-601-8165-XXX and Job Control # (JC-442048), the basis of your eligibility (list, transfer, SROA, Surplus, Remployment, Reinstatement, Training & Development and/or TAU) in the “Examination(s) or Job Title(s), For Which You Are Applying” section on the STD. 678.   Please remove any confidential information, e.g., social security number, date of birth, etc., as well as, any information regarding your LEAP eligibility and/or exam scores from your documents prior to submission.  A complete application package includes: a signed STD. 678, r esume and a copy of your California Registered Nurse License .

Equal Opportunity Employer

The State of California is an equal opportunity employer to all, regardless of age, ancestry, color, disability (mental and physical), exercising the right to family care and medical leave, gender, gender expression, gender identity, genetic information, marital status, medical condition, military or veteran status, national origin, political affiliation, race, religious creed, sex (includes pregnancy, childbirth, breastfeeding and related medical conditions), and sexual orientation.

It is an objective of the State of California to achieve a drug-free work place. Any applicant for state employment will be expected to behave in accordance with this objective because the use of illegal drugs is inconsistent with the law of the State, the rules governing Civil Service, and the special trust placed in public servants.