Nursing jobs in nursing homes W hether celebrating a resident’s with daily activities. Most, but not all, nursing 100th birthday or just making home residents are older. And although many rounds through the nursing home, residents require long-term care, others may Sue Christian loves her job. “When a resident be discharged when their health improves. smiles and says, ‘Oh, you’re here, I’m glad to (Additional types of facilities that provide see you!’ it’s a great feeling,” says Christian, long-term care to older and other residents are who cares for older adults and other residents described in the box on page 32.) of a nursing home in Columbiana, Ohio. “I Projected growth like to know that I’ve made a difference.” Christian is a licensed practical nurse who Birth rates in the United States increased focuses on caring for older people. The need dramatically in the two decades following for workers like her is growing. According to World War II. This large population group the U.S. Census Bureau, the number of people is commonly known as the “baby boomers,” ages 65 and older is expected to increase from and its oldest members are now turning 65. Elka Maria 40 million to 72 million between 2010 and As the baby-boom group continues to age, 2030. And the U.S. Bureau of Labor Statistics older Americans will represent an increasing Torpey (BLS) projects that this increasing population percentage of the total population. By 2030, will result in job growth for a variety of occu- Census Bureau data show, the 72 million pations related to caring for older people— people expected to be ages 65 and older will such as those in nursing homes. represent 19 percent of the U.S. population— This article describes some of the career up from 13 percent in 2010. opportunities in nursing homes, highlighting As mentioned previously, the growing nursing occupations. The first section gives number of older people heightens demand for an overview of work in nursing homes. The workers to care for them, including in nurs- Elka Maria Tor- second section describes three nursing occu- ing homes. According to BLS data, employ- pey is an econo- pations that are available in nearly all of these ment in nursing care facilities is expected to mist in the Office facilities: nursing assistant, licensed practical grow more than 24 percent over the 2008–18 nurse, and nurse assessment coordinator. The decade, much faster than the average for of Occupational third section discusses working conditions, all industries. That’s an increase of nearly Statistics and both good and bad. And a final section pro- 400,000 jobs over the decade. Employment vides sources for more information. And job opportunities are expected to be Projections, excellent. “I tell people, if you want a field BLS. She can be Work in nursing homes with job security, this is it,” says Genevieve reached at (202) Gipson, director of the National Network of 691–5719 or at Nursing homes, also called nursing care Career Nursing Assistants in Norton, Ohio. torpey.elka@bls. facilities, are places of residence for people Ingrid Serio, director of content manage- gov. who require ongoing medical care and help ment at the American Association of Nurse 23 Spring 2011 (cid:135) Occupational Outlook Quarterly Employment. Workers who provide direct care make up the largest segment of the indus- try. Other workers help with facility manage- ment and upkeep. In addition to the three nursing occupa- tions described in detail in this article, most nursing home workers interact directly with residents. For example, occupational, speech, and physical therapists provide rehabilitative and therapeutic care. Recreation workers and activities staff help to organize events, such as bridge games and musical performances. Dieticians and nutritionists develop residents’ dietary plans. Nursing homes also employ workers Assessment Coordination in Denver, Colo- who may have less contact with residents but Nursing home workers rado, agrees. “We don’t have a lot of nurses are essential to operations. Nursing home serve residents who need going into care for the elderly,” she says—a administrators run the facility, ensuring that ongoing care. good indicator of job security but a potential residents are safe and well cared for. Other issue in providing care for a larger number of workers prepare and serve meals to residents, older people in the coming years. clean rooms, and do laundry. And like most industries, nursing care facilities need workers Employment and wages who take care of basic business functions such Nursing care facilities employed more than as building maintenance and finance. 1.6 million people in May 2009, according Wages. As the table shows, wages in nurs- to BLS. The table below shows employment ing home occupations varied widely in May and wages for the 10 largest occupations in 2009, according to BLS. Some occupations, the industry. These occupations accounted for such as laundry and dry-cleaning workers, had about 78 percent of total employment in nurs- relatively low wages. Others, such as regis- ing care facilities. Almost all of the occupa- tered nurses, had relatively high wages. Occu- tions had an annual wage below the overall pations with higher wages typically require median of $33,190. more education than a high school diploma or Occupations with the largest employment in nursing care facilities, May 2009 Occupation Employment Median annual wage Nursing aides, orderlies, and attendants 609,440 $23,380 Licensed practical and licensed vocational nurses 212,990 41,310 Registered nurses 128,420 57,830 Maids and housekeeping cleaners 80,260 19,350 Home health aides 48,550 21,450 Food preparation workers 48,140 19,210 Cooks, institution and cafeteria 47,130 22,570 Recreation workers 33,510 23,510 Laundry and dry-cleaning workers 31,340 19,250 Food servers, nonrestaurant 31,100 19,410 24 Occupational Outlook Quarterly (cid:135) Spring 2011 equivalent—the usual minimum requirement Nursing assistants help residents with for lower wage occupations. daily living activities. Common tasks include Some high-wage occupations had higher feeding, bathing, and dressing residents and wages in nursing homes than in other indus- helping them to get around. These workers tries. Examples include occupational thera- assist residents with hygiene and personal-care pists, physical therapists, massage therapists, activities, such as washing hands and combing and speech-language pathologists. Across all hair. industries, workers in these occupations had The nursing assistant also observes above-median wages, and they earned even residents’ response to treatment and care, higher wages in nursing homes. documents their food and fluid intakes, and In some low-wage occupations, too, wages monitors their vital signs, such as blood pres- were higher in nursing homes than in other sure and pulse. And they report changes and industries. For example, combined food prepa- any health concerns to the nurse on duty. ration and serving workers in nursing homes There are many different job titles for had a median annual wage of $18,930, com- nursing assistants. Examples include nurse pared with $17,220 for these workers across aide, certified nursing assistant, and orderly. all industries in May 2009. Michael Watkins, whose title is orderly, is a Profiles in nursing nursing assistant in Rocky Hill, Connecticut. He works a variety of shifts—sometimes Workers in nursing occupations provide direct starting his day in the morning, other times care to residents and communicate with them working throughout the night. Occasionally, and their families about this care. These work- he works double shifts when his nursing home ers may have different job titles and responsi- is short-staffed. bilities, but all of them operate as a team. People who work directly with nursing Monitoring vital signs home residents usually have certain personal- ity traits—including patience, tact, and sen- is one of the tasks sitivity—that help them do their jobs. Having performed by nursing knowledge of or experience in working with assistants. older people is also helpful, and some employ- ers may even require it. Other requirements are imposed by Federal, State and local governments. Nurs- ing homes and their employees are often subject to specific laws and regulations, in part to ensure the quality of care that residents receive. Nursing occupations usually require State licensure or certification. Three types of direct-care jobs in a nurs- ing home include nursing assistants, licensed practical nurses, and nurse assessment coordi- nators. Sometimes, these workers’ tasks over- lap, but each has a distinct role in providing or ensuring quality care for residents. Nursing assistants A nursing assistant is often the first person nursing home residents see in the morning— and the last one they see at night. 25 Spring 2011 (cid:135) Occupational Outlook Quarterly When working a morning shift, Watkins 8 to 14 residents per shift to attend to, so his begins his day by visiting each of the residents time with each person is limited. in his care. He asks how they’re doing and Ensuring resident safety is also part of the how they slept, then talks to them about what work. Residents with dementia, for example, tasks he’s there to perform. Usually, he helps sometimes wander or aren’t aware of what people get from their beds to the bathroom, they are doing. “A resident might try to eat possibly into the bath or shower. He also lays something that’s not food,” says Watkins, and out their clothes and aids them in getting it’s his job to make sure that doesn’t happen. dressed. Nursing assistants may choose to special- The type of assistance Watkins gives each ize in a particular type of resident care. Medi- resident depends on the resident’s capabilities. cation aides, for example, administer certain Some residents might need help bathing or kinds of medications; restorative aides assist eating, for example; others require assistance residents with skills such as range-of-motion only to go from one place to another. exercises, walking, or dressing with one hand. During his night shifts, Watson turns and Other specialty workers include bathing aides, repositions the sleeping residents who would dining assistants, and hospice aides. otherwise develop pressure sores from staying Employment, outlook, and wages. BLS in the same position too long. He also checks classifies nursing assistants under the job on residents every few hours throughout title of nursing aides, orderlies, and atten- the night to make sure they’re comfortable. dants. In May 2009, there were more than Nursing assistants also help bring residents to 1.4 million workers in this occupation, more therapy sessions, to common areas for meals, than 609,000, or 42 percent, of whom were and to other nursing home activities—includ- employed in nursing care facilities. In fact, Nursing assistants ing spiritual ones. “We’re dealing with the nursing assistant was the largest of all nurs- ensure that residents are total person,” says Watkins. “If someone ing home occupations, making up about 37 comfortable, help them needs to go to Mass, church, or temple, for percent of total employment in the industry. with daily tasks, and example, we’ll go with him.” The job outlook for nursing assistants is While caring for residents, Watkins tries expected to be excellent. BLS data show that socialize with them. to socialize with them, too. But he might have employment in this occupation is projected to grow faster than the average for all occupa- tions over the 2008–18 decade. Many open- ings are expected to come from these newly created jobs. Other opportunities, however, will come from the need to replace workers who leave the occupation. BLS wage data show that nursing aides, orderlies, and attendants in nursing care facili- ties had a median annual wage of $23,380 in May 2009, compared with $24,040 for these workers across all industries. The highest earning 10 percent of nursing assistants in this industry had an annual wage of $32,280 or more. The lowest earning 10 percent had an annual wage of $17,390 or less. Education and training. Training requirements for becoming a nursing assistant vary by State and by employer. All nursing assistants who work in nursing homes must be on a State registry. Each State has different 26 Occupational Outlook Quarterly (cid:135) Spring 2011 Responsibilities vary, but nursing home workers operate as a team in caring for residents. guidelines for being listed on the registry, medications, such as dressing wounds and dis- but all call for nursing assistants to complete pensing prescribed drugs. Licensed practical State-approved training and competency nurses also communicate with other health- requirements. care team members regarding residents’ care. Training is offered at some high schools, Licensed practical nurses in nursing as well as at vocational-technical schools, homes often supervise nursing assistants. community colleges, and nursing homes. Christian, for example, is a nurse aide super- State boards of nursing maintain information visor who oversees the work of all nursing about approved programs. Workers also learn assistants in her facility. Other licensed practi- some of their skills on the job and through in- cal nurses at her nursing home are assigned to service training provided by their employer. particular groups of residents—and nursing After they are listed on a State regis- assistants often turn to these nurses first with try, nursing assistants may be referred to as questions about residents in those groups. certified nursing assistants, licensed nursing Although Christian is concerned with assistants, or similar titles. residents’ well being, her primary focus is on the nursing assistants and the work they are Licensed practical nurses doing. “I look in on residents,” says Christian, Licensed practical nurses care for residents in “but I’m checking to be sure that the aide is many ways. Their tasks may include providing doing the job correctly. I go from room to bedside care or increasing residents’ personal room, looking over the residents to see: Is comfort. their hair combed? Are they dressed properly? These workers, who in some States are Are their glasses clean?” called licensed vocational nurses, tend to Christian handles any staffing issues that residents’ health under the direction of doctors arise. For example, if a resident has the flu, and registered nurses. They monitor residents’ Christian might ensure that the aide assigned well-being and administer treatments and to that resident receives extra support to 27 Spring 2011 (cid:135) Occupational Outlook Quarterly accommodate the additional time needed to worked in rehabilitation. As is the case with care for the sick resident. She also has admin- nursing assistants, specialization for licensed istrative and managerial tasks, such as creat- practical nurses often leads to advancement in ing work schedules, providing training, and the occupation. hiring and, if necessary, terminating nursing The extent of a licensed practical nurse’s assistants. duties is determined by the State in which he Most licensed practical nurses in a nurs- or she works. In some States, for example, ing home work closely with nursing assistants, licensed practical nurses administer certain and some of their job tasks are similar to medications or start intravenous therapy, or those of nursing assistants. For example, some IVs. Recognizing the additional training that licensed practical nurses help to bathe or feed licensed practical nurses get, State regulations residents. generally allow these nurses to perform more Licensed practical nurses also create and complex tasks than nursing assistants. update resident care records, documenting any Employment outlook, and wages. In changes in residents’ conditions. Some help to May 2009, BLS data show, there were about develop resident care plans. 213,000 licensed practical nurses and licensed Communicating with residents’ families vocational nurses employed in nursing care is another part of a licensed practical nurse’s facilities. They accounted for nearly 30 job. For example, these nurses might educate percent of the occupation’s nearly 729,000 residents and their families on health-related workers. topics, such as self-care techniques. Or they The job outlook for licensed practi- might address family members’ problems or cal nurses is very good. BLS expects much concerns. faster than average growth of employment Sometimes, licensed practical nurses of licensed practical and licensed vocational specialize in a particular type of care. Before nurses over the 2008–18 decade. As with becoming a supervisor, for example, Christian nursing assistants, some openings will result In certain States, licensed practical nurses may administer some medications or start IV therapy. 28 Occupational Outlook Quarterly (cid:135) Spring 2011 from the creation of these new jobs, and some Licensed practical nurses will arise from the need to replace workers in nursing homes who leave the occupation. According to BLS data, the May 2009 communicate with median annual wage for licensed practical residents about their nurses in nursing homes was higher than treatment. that for the occupation across all industries. In nursing care facilities, licensed practical and licensed vocational nurses had a median annual wage of $41,310, compared with the median wage for all licensed practical and licensed vocational nurses of $39,820. The highest paid 10 percent of licensed practi- cal and licensed vocational nurses in nursing care facilities had an annual wage of $55,890 or more. The lowest paid 10 percent had an annual wage of $31,410 or less. Education and training. All licensed practical nurses must be licensed by the State in which they work. For licensure, every State requires that workers complete an approved training program and pass an exam, although specific requirements vary by State. at designated intervals afterward. The nurse Training programs for licensed practi- assessment coordinator manages this data col- cal nurses typically last about 1 year and are lection process from start to finish. offered at vocational-technical schools and community colleges. State boards of nursing Nurse assessment coordinator and reg- provide a list of accredited programs. istered nurse Carol Maher of Mission Viejo, Employers may require additional quali- California, spends much of her workday fications. To work in nursing homes, for interviewing residents and their families. “I’m example, prospective licensed practical nurses asking them about their physical comfort, how may need previous experience in dealing with they feel emotionally, how we’ve been caring older people. for them,” she says. Nurse assessment coordinator Coordinators learn a lot about residents during these interviews, including ways to Ensuring quality care in a nursing home is the make their stay more enjoyable. Sometimes, goal of nurse assessment coordinators. These even a small change makes a big difference. workers manage procedures to evaluate resi- “It can be as simple as wanting a cup of coffee dents’ care. The process helps to confirm that before getting out of bed,” says Serio of the each resident receives appropriate services types of suggestions received during assess- and attention. ments. For many residents, a nursing care Nurse assessment coordinators are more facility becomes their home—and making commonly known as MDS coordinators the environment more home-like significantly because their work revolves around the MDS, improves their quality of life. or Minimum Data Set, a standardized tool for assessing residents’ care. The MDS assess- As part of the evaluation process, nurse ment process measures the physical and emo- assessment coordinators review a resident’s tional well-being of all nursing home residents medical records. They share information with when they are admitted to the facility and other staff members and work with them to 29 Spring 2011 (cid:135) Occupational Outlook Quarterly Residents are reassessed at least quarterly. Nurse assessment Each assessment has a specific deadline, and coordinators interview nurse assessment coordinators must schedule residents and identify interviews and meetings to hit these target areas of concern. dates. The specific tasks of a nurse assessment coordinator vary from one facility to another. In some nursing homes, for example, nurse assessment coordinators are the only ones who conduct the initial assessment interviews. In others, the work is shared, with each staff member interviewing residents on topics related to their expertise. Nurse assessment coordinators might also be responsible for ensuring facility compli- ance with other Federal and State regulations. And some coordinators have additional nurs- ing or administrative duties. Nearly all nursing homes have at least one nurse assessment coordinator. In smaller facil- ities, the director of nursing may perform the coordinator’s tasks. Many nurse assessment coordinators have been trained as registered nurses. Others are licensed practical nurses who are supervised by registered nurses. Employment, outlook, and wages. BLS develop a comprehensive care plan for each does not collect data specifically on nurse resident. assessment coordinators. It does, however, The team approach to planning care is a have data on registered nurses and licensed key to ensuring effectiveness. “Care can’t be practical nurses, two occupations from which in silos, or it won’t be efficient,” says Maher. nurse assessment coordinators often advance. If a resident is losing weight, for example, the In May 2009, there were nearly 2.6 million dietitian, certified nursing assistant, and resi- registered nurses of all types, including about dent’s family might all confer on a solution, 128,000 (5 percent) working in nursing care such as changing the resident’s diet or giving facilities. And, as mentioned in the previous the resident easier-to-use eating utensils. section, 213,000 of the 729,000 licensed prac- The assessment process can help identify tical and licensed vocational nurses employed concerns and foster communication between in May 2009 worked in nursing care facilities. caretakers, residents, and families. In some Data from the American Health Care cases, the nurse assessment coordinator may Association, however, suggests that relatively have to perform additional assessments. few of those nurses worked as nurse assess- Coordinators collaborate with other team ment coordinators. The association estimates members in weekly meetings, discussing resi- that there were about 11,000 MDS coordina- dents’ care to make sure needs are being met. tors in nursing facilities in 2008, the most “Our goal is to get people to their highest level recent year for which data are available. of functioning—which might be in a long- The employment outlook for nurse assess- term care facility, or it might be in assisted ment coordinators is expected to be very living or back at their own home,” says Maher. good, according to industry sources. And BLS “We help explore all the options.” projects much faster than average growth for 30 Occupational Outlook Quarterly (cid:135) Spring 2011 both registered nurses and licensed practical exam before they may work in the occupation. nurses over the 2008–18 decade, which should States may have other requirements for licen- result in many opportunities for both occupa- sure, as outlined by State boards of nursing. tions. Most nurse assessment coordinators have BLS does not collect wage data on nurse first worked as a nurse. Experience working assessment coordinators. Industry sources in nursing homes is helpful and is sometimes suggest that their earnings range from about required by employers. Many nurse assess- $40,000 to nearly $70,000. BLS data show ment coordinators learn the details of their that the median annual wage for registered positions on the job. Special MDS training nurses in nursing care facilities was $57,830 in and certification are available but are not usu- May 2009, compared with $63,750 for regis- ally necessary to get a job. tered nurses in all industries. The highest paid 10 percent of registered nurses in nursing care Rewards and challenges facilities earned $80,440 or more, and the lowest paid 10 percent earned $42,560 or less. Jobs in nursing homes have both rewards and As stated previously, licensed practical nurses challenges, say workers—and caring for resi- in nursing care facilities had a median annual dents is often at the core of both. wage of $41,310 in May 2009, with the highest Most workers say some job satisfaction paid 10 percent making $55,890 or more and comes from knowing that they make a dif- the lowest paid 10 percent making $31,410 or ference in residents’ lives. “The best part of less. my job is being able to help people who can’t In most occupations, workers who have help themselves,” says Watkins. Maher enjoys more experience typically earn a higher wage taking assessments because it creates opportu- than workers with little experience. Nurse nities to have a positive impact on treatment. assessment coordinators typically have many “I find ways to improve every resident’s care,” years of experience, so they may be paid more Nursing home she says, “to help each of them become physi- than other nurses who have less experience. workers know that cally better, happier.” Education and training. Nurse assess- Even if workers aren’t able to improve the care they provide ment coordinators are trained as either residents’ lives directly, they still find it grati- makes a difference in registered nurses or licensed practical nurses. fying to contribute to a better quality of life. Therefore, they must meet the requirements of people’s lives. “It’s nice to know that people aren’t at home, one of these two occupations. Registered nurses have several training options. They may earn a 2- or 3-year associ- ate degree in nursing; earn a 4-year bach- elor’s of science degree in nursing; or, if they already have a bachelor’s degree in another discipline, complete a 12- to 18-month accel- erated program for a bachelor’s of science in nursing or a 2-year accelerated program for a master’s degree in nursing. (A smaller num- ber of registered nurses earn their credentials through diploma programs at hospitals, which take about 2 to 3 years.) Licensed practical nurses, as explained previously, usually complete a State-approved program, which typically takes about 1 year. Both registered nurses and licensed practical nurses must pass a national licensing 31 Spring 2011 (cid:135) Occupational Outlook Quarterly