travel nurse lpn pay

How Much Do Travel Nurses Make?

Average Pay for Travel Nurses

Travel nursing pay explained, highest and lowest paying states for travel nurses.

• Highest Paying Travel Nurse Specialties
• Ways to Increase Pay

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Travel nursing offers a unique work experience with the opportunity to earn above-average hourly wages. These wages may even exceed those of other registered nurses (RNs) with the same education and credentials.

Travel nurses are typically employed by travel nursing agencies and work assignments across the country wherever nurses are needed. Because each assignment is different, the total annual income for travel nurses can vary significantly. Factors include the details of the pay package, where the assignment is located, and nursing specialty.

On this page you will find the most recent information about travel RN salaries, benefits, specialties, and the states with a high demand for travel nurses.

Fast Facts About Travel Nurses

• Travel nurses generally earn as much or more than staff nurses with the same experience and qualifications.
• Lodging reimbursement and tax advantages impact travel nursing salaries.
• The most in-demand travel nursing specialties include labor and delivery, emergency room, and medical-surgical/telemetry.

The average travel nurse salary varies greatly depending on the work assignment. Depending on travel location, these practitioners can earn between $3,000 and $7,000 per week, averaging a 36-hour work week. According to Vivian , a healthcare jobs marketplace, and the U.S. Bureau of Labor and Statistics (BLS), travel nurses earn jan average of $2,183 per week, while RNs earn a mean hourly wage of $42.80. However, aspiring travel nurses should note that living on the road leads to additional personal expenses, so the increase in pay accounts for living accommodations.

Max Weekly Pay

Average Total Weekly Pay

Source: Vivian , September 2023

Travel nurse pay differs from full-time nursing positions because agencies offer hourly rates for each assignment, meaning RNs can shop around and find opportunities with ideal pay. In contrast, RNs working full time at hospitals, physicians’ offices, and other facilities usually rely on raises or additional education to increase their earning potential.

Practitioners considering this role also need to explore what take-home pay looks like for travel nurses . Nursing agencies set their own conditions, so pay packages vary. For instance, organizations may offer an hourly base pay with additional stipends to cover housing or meals, while other companies may offer a higher hourly rate to account for additional expenses.

Travel nurse salaries vary by state and region. Locations in need of RNs typically offer more competitive wages. In fact, the popularity of a particular region can influence travel nurses’ earning potential. Less popular locations may pay more, while desirable locations may pay less. Likewise, states with a higher cost of living offer higher wages relative to living costs.

According to 2023 data from Vivian, the top-paying states for travel RNs included New Jersey , California, and Alaska. Practitioners also want to consider the highest-paying specialties to determine earning potential which may vary by state. The following section includes the top specialties in demand.

Highest Paying Travel Nurse Specialities

Typically, nursing specialties that lack licensed practitioners offer more pay than other specialties, which further increases earning potential for travel nurses. Higher acuity facilities also offer higher pay, as they need skilled practitioners who can meet their patients’ needs. Here are five in-demand specialties for travel nurses.

Labor and Delivery

Emergency room, medical-surgical/telemetry, critical care – intensive care unit, operating room registered nurse, 4 ways to increase pay as a travel nurse.

While travel nurse pay may exceed traditional full-time RN salaries, travel nurses can additionally increase their earning potential by considering factors like demand for specialties, understaffed or unpopular shifts, and locations in need of skilled RNs.

Travel nurses should examine the full benefits package to determine if jobs can provide sufficient take-home pay. For instance, regions with a high cost of living may impact how much practitioners actually earn if stipends do not cover all costs.

Frequently Asked Questions: Travel Nursing Salaries

How much does a traveling nurse make per year.

Travel nurse salaries vary significantly, especially since the outbreak of COVID-19. Factors that can influence earning potential include geographic location and specialty. However, travel RNs should anticipate working 46 weeks a year and earning about $2,183 on a weekly basis .

Do travel nurses get paid more?

Travel nurses typically earn more than full-time salaried RNs because they often take job assignments where there is a nursing shortage. Travel nurse agencies also pay practitioners by the hour and offer additional benefits, including housing and meal stipends.

Is travel nursing worth the money?

Travel nurses generally earn more than salaried RNs. However, practitioners should consider their lifestyle as well. For instance, an RN with a family may not feel the additional pay outweighs time at home, while another practitioner may find the pay suitable and enjoy the travel opportunities.

Do travel nurses get time off?

Travel nurses often do not receive time off since they work hourly and take temporary job assignments. While assignments vary, travel nurses should plan to work for 8-26 weeks at a time. Most travel nurses schedule time off between job assignments.

Learn More About Travel Nurses

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Travel Nurse Salary: How Much Do Travel Nurses Make?

• Travel Nurse Salary
• Salary Factors
• Salary by Specialty
• Highest Paying States
• Highest Paying Cities
• Top Paying Agencies
• How to Make More
• Related Careers
• Final Thoughts & Next Steps

How Much Do Travel Nurses Make?

The average annual travel nurse salary in the US is  $105,021 or $50/hr, according to  ZipRecruiter  as of May 2023. This is significantly higher than the average salary for registered nurses overall, which is $81,220 per year or $39.05 per hour per the BLS . 

>> Click here to see available high-paying travel nurse opportunities!

Travel nurse salaries range widely across the country, with the lowest earners making $40,000 and the highest earners making $155,500 annually!

If you are a Registered Nurse (RN) who has ever considered traveling the country and wants to know how much travel nurses earn, you’ve come to the right place! This travel nurse salary guide will explain everything you need to know about how much travel nurses can make. Including:

• Types of travel nurses who make the most money
• Travel nurse salaries by city and state incomes
• Top-paying travel nurse agencies
• How to increase your salary as a travel nurse

Factors That Impact Travel Nurse Salaries

It is important to remember that travel nursing salary is dependent on several factors, including:

• Nursing specialty
• Full-time or part-time employment
• The shifts you work: day shift, night shift, mid-shifts, or weekends
• Bonus income

Also, travel nurses who work holidays often receive time-and-a-half or double-time pay, and in some cases, even more!

In addition, depending on the circumstances, travel nurses may also receive “crisis” pay due to needing to fill staffing urgently. If you have the desire and flexibility to move to another city or state quickly, a “crisis” assignment might be a great option for you.

Travel Nurse Salary by Specialty

What do travel nurses do that warrants their higher salaries? While flexibility is a significant factor, your travel nurse salary will also change depending on your nursing specialty.

Travel CRNA

Certified Registered Nurse Anesthetists (CRNAs) are the top-paid nursing specialty. The same holds true for CRNAs who take travel assignments as well. According to ZipRecruiter , CRNA travelers earn an average annual income of $194,352 or $93/hr. The highest earners make as much as $311,500!

Operating Room Travel Nurse

Operating Room (OR) travel nurses are in high demand at various locations around the country. ZipRecruiter found that operating room travel nurses earn an average annual income of $181,460 annually or $87/hr. The highest earners make as much as $286,000.

Emergency Room Travel Nurse

ZipRecruiter reports that ER travel nurses earn an average annual income of $83,503 annually or $40/hr. However, they add that the highest earners make as much as $171,500.

Intensive Care (ICU) Travel Nurse

According to ZipRecruiter , the average annual salary for ICU travel nurses is $143,416 annually or $69/hr. However, the highest earners make as much as $263,500.

Travel Nurse Practitioner

The average travel nurse practitioner salary is $140,086 annually or $67/hr, according to ZipRecruiter .  However, salary is often dependent on location and specialty. The highest-earning travel nurse practitioners make as much as $243,500.

Neonatal Intensive Care Unit (NICU) Travel Nurse

NICU travel nurses earn an average income of approximately $173,017 annually or $83/hr, according to ZipRecruiter . However, incomes across the country can range widely, with bottom earners making $56,000 and top earners bringing in $281,500.

Med-Surg Travel Nurse

ZipRecruiter reports that med-surg travel nurses in the US earn an average annual income of $118,997 or $57.21/hr. However, per-hour incomes can reach as high as $134.38, depending on your location and facility.

Telemetry Travel Nurse

ZipRecruiter states that telemetry Travel nurses earn an average annual income of $124,122 annually or $60/hr. However, top earners bring in as much as $174,500.

Top Paying States for Travel Nurses

Location can make a huge difference in salary as a travel nurse. ZipRecruiter reports that the states that offer the highest pay for travel nurses include:

• New York: $128,277 annually or $61.67/hr
• Arizona: $109,776 annually or $52.78/hr
• Wyoming: $109,765 annually or $52.77/hr
• Hawaii: $109,653 annually or $52.72/hr
• Tennessee: $107,708 annually or $51.78/hr
• Massachusetts: $107,000 annually or $51.44/hr
• New Jersey: $106,901 annually or $51.40/hr
• Washington: $106,086 annually or $51.00/hr
• West Virginia: $106,044 annually or $50.98/hr
• New Hampshire: $105,438 annually or $50.69/hr

Top Paying Cities for Travel Nurses

ZipRecruiter reports that the cities that offer the highest pay for travel nurses include:

• Barrow, AK: $137,200 annually or $65.96/hr
• San Jose, CA: $133,873 annually or $64.36/hr
• Oakland, CA: $132,042 annually or $63.48/hr
• Antioch, CA: $129,387 annually or $62.21/hr
• San Francisco Bay Area, CA: $128,781 annually or $61.91/hr
• Lebanon, NH: $128,674 annually or $61.86/hr
• New York, NY: $128,277 annually or $61.67/hr
• Hayward, CA: $127,865 annually or $61.47/hr
• Vallejo, CA: $127,791 annually or $61.44/hr 
• Seattle, WA: $127,691 annually or $61.39/hr

Top Paying Agencies for Travel Nurses

There are multiple top-paying travel nurse agencies across the US. It is important to remember that your pay package depends on several factors, and income may vary widely depending on location and the needs of the facility. When a healthcare facility has more urgent needs for travel nurses, the pay ranges typically increase.

>> Related: Travel Nurse Requirements

Aya Healthcare

Aya Healthcare is one of the largest travel nurse agencies in the country, and they offer a wide range of travel nurse opportunities for various nursing specialties and allied healthcare positions. 

Fusion Medical Staffing

Fusion is another large nurse travel agency with many opportunities for nurses to choose their top travel destinations. Their website reports that one of the biggest perks of working with them is that they offer dedicated contacts available every day and night, 24/7.

Axis Medical Staffing

Axis Medical Staffing has won awards for “Best Customer Service” by Verywell Health and “Top Travel Nursing Company 2022” by Travel Nursing Central. 

Travel Nurse Across America

The TNAA website boasts highly skilled recruiters, housing experts, and clinical and quality insurance that prepares their travel nurses for success. 

Gifted Healthcare

Gifted Healthcare is another large travel nursing agency that reports that they aim to open the door to the right opportunities for their clinicians. In fact, their website reports that 90% of travel nurses report that their assignments aligned perfectly with their skills and expectations. 

TotalMed Staffing

Headquartered in Appleton, WI, TotalMed Staffing has several other locations across the country, such as California, Illinois, Tennessee, and North Carolina. They serve various types of healthcare facilities across the country.

Ventura Medstaff

Ventura Medstaff prides itself on integrity. Their website makes it easy to find a match for various types of healthcare specialties in the right location and facility across the country.

Tailored Healthcare

The Tailored Healthcare website reports that travel nurses are rewarded professionally with high-paying travel assignments, Platinum Shield Benefits, and everything paid for upfront. In addition, the company celebrates its nurses year-round with praise, gifts, and best-in-class bonuses.

Titan Medical 

Titan Medical Group states that they help their clients “find your place.” They feature various jobs on their website daily and make it easier for clients to find their next travel assignment.  

MedPro Healthcare

Medpro Healthcare offers incredible benefits, including competitive compensation, travel reimbursement, health insurance, short and long-term disability, 401K, Continuing education, and even referral bonuses.

How to Increase Your Salary as a Travel Nurse

No matter where you live and work as a travel nurse, there are often opportunities to increase your salary.

Be Flexible With Your City and State

When you live and work in a city with a higher cost of living, you will also be compensated at a higher rate. For example, travel nurses who work in areas such as New York City, Los Angeles, San Francisco, or Seattle will earn significantly more income than travel nurses who choose to work in lower-cost-of-living areas. 

Consider Your Specialty(s)

If you have been cross-trained in more than one nursing specialty, you may want to see which specialties pay the most through your travel agency. For example, if you usually work as an ICU nurse, but a facility has crisis needs for telemetry nurses and will pay top dollar for that specialty, then you may want to consider accepting that travel assignment. After all, these are temporary assignments, and if you decide you don’t like them, you won’t have to stay for long.

Ask About Per Diem Daily Pay

Many nurses qualify for additional per diem pay for travel nurse housing , incidentals, and meals during their travel assignments. Talk to your travel agent to see if this applies to you.

Choose Shifts Wisely

Career and travel nurses are typically paid a few dollars more per hour for working less desirable shifts such as night shifts, mid shifts, and weekends.

In addition, travel nurses who work holidays often receive time and a half or double time pay!

Talk About Bonuses

Your travel agency will need to explain your bonus structure, as they can differ from agency to agency. However, here are a few of the different types of bonuses you may be eligible for as a travel RN:

• Agency bonus: Added pay from your travel agency
• Retention bonus: Your agency will often pay you a fee for referring your nurse and allied healthcare professional friends to their agency.
• Retention bonus: Agency-paid bonuses for nurses who continue to accept travel bonuses from the same agency.

Find Crisis or Strike Pay

Healthcare facilities in dire need of nursing staff during a public healthcare crisis, such as the COVID-19 pandemic or during a nursing strike, often will pay travel nurses significantly higher wages than during non-dire times. Talk to your travel agency to find out where the most significant staffing needs are. 

Consider Looking at Different Agencies

If you are ever disappointed with your travel pay or hear through the grapevine that other agencies pay significantly more, consider looking at different agencies. It is also wise to build relationships with other travel nurses so you can talk freely about what to expect at different agencies.

Consider Finding Your Own Housing

Many agencies offer a housing stipend and then secure your housing for you. However, if you find your own housing, you may be able to find something less expensive and pocket the rest of the money.

>> See more travel nurse salary tips in How to Make the Most Money as a Travel Nurse

Salaries of Related Nursing Careers vs. Travel Nursing

The following are salaries of non-traveling nursing specialties, according to ZipRecruiter:

• NICU Nurse : $136,592 annually or $66/hr
• Surgical Nurse: $120,699 annually, or $58/hr
• Postpartum Nurse: $108,952 annually or $52/hr
• Telemetry Nurse: $95,179 annually, or $46/hr
• ICU Nurse : $92,568 annually or $45/hr
• Emergency Room Nurse : $83,503 annually or $40/hr

Travel Nurse Salary: Final Thoughts & Next Steps

The high salaries alone are enough to make dozens of nurses excited to enter travel nursing. But the perks don't stop at pay - travel nurses get to see the world, interact with patients across cultures, and enjoy non-taxed travel stipends. If all that sounds enticing to you, check out our guide on how to become a travel nurse to start your dream career today!

Travel Nurse Salary FAQs

Do travel nurses get paid well.

• ZipRecruiter reports that as of May 2023, travel nurses in the US earned an average annual income of $105,021 or $50/hr. They also add that salaries range widely across the country, with the lowest earners making $40,000 and the highest earners making $155,500 annually! 

What is the highest travel nurse salary?

• CRNAs travelers are the top-paid travel registered nurse specialty.  According to ZipRecruiter, CRNA travelers earn an average annual income of $194,352 or $93/hr. The highest earners make as much as $311,500! 

Why are travel nurses paid so much?

• Travel nurses help to fill staffing gaps and often accept assignments in areas with severe or “crisis’” nursing shortages. For their travel flexibility and ability to work in sometimes hard-to-fill areas, they are typically paid a higher compensation.

Sarah Jividen , RN, BSN, is a trained neuro/trauma and emergency room nurse turned freelance healthcare writer/editor. As a journalism major, she combined her love for writing with her passion for high-level patient care. Sarah is the creator of Health Writing Solutions , LLC, specializing in writing about healthcare topics, including health journalism, education, and evidence-based health and wellness trends. She lives in Northern California with her husband and two children. 

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2024 Travel Nurse Salary + Job Outlook

Travel nurses work in specific locations for limited and usually predetermined timeframes of anywhere from 13 to 16 weeks. Though they may work in any type of facility – hospitals, doctors’ offices, and long-term care facilities – they get to choose where they work, which helps prevent boredom. Travel nurses also earn handsome salaries that rival the average salaries of BSN-educated registered nurses (RNs). Here, you will learn more about the average travel nurse salary and what you can expect if you choose this exciting career path.

How Much Does a Travel Nurse Make?

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Travel Nurse Salary Guide | 2023

What is a travel nurse.

Travel nurses are registered nurses that work short-term contracts to fill the needs of hospitals, clinics, long-term facilities, and other healthcare institutions. Travel nurses can help when there are nursing shortages. However, it is not always a long-term solution.

Travel nursing is very enticing to those who want increased flexibility within the nursing sector that traditional bedside nursing might not offer.

Looking for open travel nurse assignments? Speak with a recruiter today!

How Much Do Travel Nurses Make?

Travel nurse salaries vary depending on the location and specialty. Most recently travel nurses have seen a decline in salaries as compared to several years ago. The COVID-19 pandemic dramatically increased wages for travel nurses, and many left the bedside in order to travel the country but also cash in on the big paychecks. While now the salaries are not as large for contracts, there are still a plethora of contracts available at a competitive wage across the country.

ZipRecruiter.com reports the national average for travel nurses is $118,400 per year. The highest-paying states are New York, California , and Idaho while the lowest reported salaries are in Louisiana and North Carolina. Even though North Carolina has the lowest travel nurse salary, the annual travel nurse salary is still more than the $77,600 national average for staff nurses according to the BLS .

But don’t forget other ways to make money as a travel nurse, such as earning points or miles on all the travel that you already have to do. We now have travel nursing credit cards just for nurses to earn while they travel.

Travel Nurse Salary by State

Salaries and stipends vary by state and city , as do housing and cost of living. Here’s a breakdown of travel nurse salaries and hourly wage for all fifty states, going from highest to lowest.

Source: ZipRecruiter.com

Find available, high-paying travel nurse opportunities.

Wages for travel nurses involve more than a straight hourly rate. Travel nurses can receive non-taxed stipends for housing and living expenses, and those stipends are paid on top of your hourly rate. Other benefits may include, depending on the staffing agency:

• Medical, dental, and vision insurance
• 401K investment options
• Sign-on, completion, and referral bonuses
• Free continuing education courses
• License Reimbursement
• Weekly/Bi-weekly Pay
• Tax Advantage Plan
• Life Insurance
• Liability Insurance, Disability Insurance, and Worker’s Compensation
• 24/7 Support

It’s important to remember that travel nurses are paid (and taxed) differently than staff nurses . Travel nurses are paid through agencies, not the hospital, so you have to look at your total pay. This includes your hourly base pay + your non-taxable stipends, which is what things like housing and meals are considered.

What Does a Travel Nurse Package Include?

Travel nurse packages will vary depending on the company as well as the individual. For example, one travel nurse may take a housing stipend while another might take the company-provided houses. These small differences are important to remember when investigating travel nurse contracts and also speaking to your peers. Furthermore, some travel nurse companies will have exclusive contracts with healthcare institutions, and packages will look different based on the exclusivity.

There are three major components to all pay packages:

• Taxable hourly pay
• Housing Stipend
• Meal and Incidentals Stipend

Taxable Hourly Rate

The hourly pay is the dollar per-hour amount for each hour worked. It is the taxable portion of the pay package, which is important to remember. The actual amount you are paid will vary depending on the agency. Travel nurse agencies will want to pay you the least amount possible in order to make packages look the most attractive to travel nurses. The larger the hourly wage, the more taxes are taken out and as a result less weekly income.

Housing, Meal, and Incidental Stipends

This portion of the pay package is tax-exempt since non-taxable money is not considered income. This is the most alluring part of a travel nurse pay package and where travel nurses will make the most money. This money is directly determined by the travel nurse company .

These stipends will also vary depending if you decide to take housing provided by the company or find your own. If you decide to take company-provided housing then you would not receive a housing stipend. Many travel nurses decide to take the housing stipend and then find their own living arrangements. This can help nurses take home extra non-taxable pay. But be careful, it also can be harmful.

For example, if the housing stipend is $1,200 and you find an apartment for $1,000 then you will get to keep the extra $200. Unfortunately, if housing is more than the housing stipend provided by the company then you are responsible for the difference.

Pro tip: Look at housing costs before signing your contract!

As an example, a standard total pay package could look something like this:

*Assumes $20 per hour at 40 hours per week, minus taxes

Understanding Your “Tax Home”

In order to qualify for these non-taxable stipends or reimbursements, one must maintain what the IRS calls a “tax home.” A tax home is your place of residence that you maintain and pay for (either by rent or mortgage) while you are out on your travel assignment. Ideally, the IRS would like a travel nurse to take an assignment somewhere and then return to their tax home where they maintain a PRN or full-time nursing job.

Travel nurses that have a tax home will need to maintain proof of this. It’s important to keep all receipts that prove you are paying to maintain your primary residence (e.g., house sitters, utilities, home maintenance expenses).

Per IRS Publication 463 , three factors are used to determine if a location/residence qualifies as a tax home. These are:

• You perform part of your business in the area of your main home and use that home for lodging while doing business in the area.
• You have living expenses at your main home that you duplicate because your business requires you to be away from that home.
• You have not abandoned the area in which both your historical place of lodging and your claimed main home are located; you have a member(s) of your family living at your main home; or you often use that home for lodging.

Most travel nursing agencies will have you sign a form stating that you do have a tax home. If you do not have a residence that you are planning on maintaining when you are traveling, you will be referred to as an itinerant worker. As an itinerant worker, you will be required to pay taxes on all income earned including stipends and reimbursements. When applying with different travel agencies, make sure they are aware of your itinerant status. You can get more information about tax homes here .

Itinerant status is not ideal and will cause a big difference in take-home pay. It can be confusing to navigate the difference between tax home and itinerant status. Speaking to a financial planner and/or accountant specializing in travel nurse pay is helpful. As a best practice, travel nurses are encouraged to return to their permanent residence between contracts.

What Factors Affect Travel Nursing Pay?

There are numerous factors that can affect travel nursing pay. Some will be in your control and others will not. These include

The specific location of the assignment most heavily influences travel nurse pay. Simply put, pay rates often reflect the cost of living in the area and also regional trends. Historically speaking, the highest-paying states for travel nurses include California , Texas , Massachusetts, Washington , and New York .

Southern states, like Mississippi and Alabama, typically have lower living costs and in turn, lower travel nurse pay. Destination locations, like Hawaii, typically do not have the most desirable pay packages because the locations are highly sought after. Companies know that there are many travel nurses who are excited about the surf and sand of Hawaii, so pay packages are reflective of that.

The travel nurse’s specialty also impacts pay. Medical surgical nurses, long-term care nurses, and clinic nurses will see significantly lower rates than other specialties, but this is generally the case even for staff nurses. Increased certifications, credentials, and skills will command higher pay. Historically speaking, the top-paying travel nurse specialties are:

• Intensive Care Unit (ICU)
• Labor & Delivery
• Neonatal Intensive Care Unit (NICU)
• Operating Room (OR)
• Post-anesthesia Care Unit (PACU)

Night shift assignments are generally more prevalent in the world of travel nursing. The increased need and the less desirable shift means that many hospitals offer higher rates for their night shift assignments. If you want to make the most money as a travel nurse, flexibility is key.

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How Travel Nurse Pay Works: A Comprehensive Guide

Table of Contents

Understanding travel nurse pay: your comprehensive guide.

Travel nursing is an exciting career option for registered nurses, offering the opportunity to explore new locations while helping patients in different healthcare facilities. As a travel nurse, understanding your pay is important to help you make informed decisions about your career and financial future. In this guide, we explore how travel nurse pay works, the factors that influence your earnings, and how to negotiate your contract to get the best pay package possible.

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How Does Travel Nurse Pay Work?

Travel nurse pay can be a complicated topic for many healthcare professionals. Unlike staff nurse positions, travel nursing contracts often come with multiple variables that can impact your take-home pay. This can include the bill rates at healthcare facilities, additional benefits like housing stipends, and vendor management fees that certain travel nursing companies apply to your pay. In this article, we will explore these various factors and dive deeper into how your pay works as a travel nurse.

Taxable Base Rates: What You Need to Know

First and foremost, it's essential to understand that your taxable base rate is the core component of your travel nursing pay package. As a travel nurse, this is the hourly wage that is taxed, similar to how a staff nurse is paid. This ensures you remain compliant with tax laws while working in your nursing position. Importantly, taxable base rates can vary between different travel nursing agencies, so it is essential to be aware of the rate you are receiving when comparing offers.

Tiered Bill Rates: How They Affect Your Earnings

Healthcare facilities typically pay travel nursing companies a bill rate for their services, which in turn covers your pay, benefits, and agency overhead costs. Some facilities use a tiered bill rate system, meaning the rates they pay to travel nursing companies can fluctuate based on specific factors. For example, a hospital may offer a higher bill rate for a nursing position in a hard-to-fill specialty or for an urgent need, which can sometimes result in increased pay for the travel nurse.

Being aware of tiered bill rates can be helpful when comparing travel nursing contracts and understanding the basis of your earnings. By exploring opportunities with higher bill rates, you could potentially maximize your earnings during your assignment.

Gross Profit Margin: Understanding Your Agency's Profit

Travel nursing companies make their profit by skimming some of the bill rates paid by healthcare facilities after covering the costs of your pay, benefits, and company overhead. This profit is referred to as the gross profit margin, and it's an important aspect to understand when examining the difference in pay between multiple agencies.

A transparent travel nursing agency should be able to provide a sample breakdown of how much from the bill rate is allocated towards your pay, benefits, payroll costs (e.g., taxes and Social Security), liability insurance, and company overhead. This understanding can empower you to ensure you're getting a fair deal and to potentially negotiate better pay and benefits if there's room for it within the bill rate.

Breaking Down the Travel Nursing Pay Package

Now that we have a grasp of taxable base rates, bill rates, and gross profit margin, let's dive into the other aspects of the travel nursing pay package, including travel stipends, housing reimbursements, and vendor management fees. These factors can have a profound effect on your final take-home pay, so it's essential to understand and compare them carefully when considering travel nursing contracts.

Travel Nursing Salary: Factors That Influence Your Earnings

Travel nursing agencies typically offer a benefits package on top of your taxable base rate, which can include housing stipends, travel reimbursements, and other tax-free reimbursements. It's important to understand how these factors work in addition to your base pay to get a full picture of your overall earnings on an assignment.

For instance, housing stipends might be offered based on the cost of living in your assignment area, while your travel stipend could cover any expenses related to commuting to and from your tax home. Some agencies may also offer shift differentials, overtime, certification reimbursement, or other bonuses that can influence your pay. Keep these factors in mind as you explore travel nursing contracts and compare offers.

Vendor Management Fees: What They Are and How They Affect Your Pay

Vendor management fees are another crucial aspect of the travel nursing pay package. Some healthcare facilities employ a Vendor Management System (VMS) to streamline the process of onboarding and managing temporary staff, including travel nurses. These VMS companies typically charge a small percentage of the bill rate as their fee, which is ultimately passed on to the travel nursing agency in the form of a reduced bill rate.

When a vendor management fee is taken into account, it can potentially influence the bottom line of your pay package. Agencies might have less flexibility in offering higher pay or better benefits given the reduced bill rates. Understanding this aspect of the system can help you set realistic expectations for pay when working with healthcare facilities that use a VMS.

Agencies Gross Profit: How It Affects Your Paycheck

Lastly, it's crucial to reiterate the connection between your travel nursing pay and the agency's gross profit. As mentioned earlier, travel nursing companies make their money by allocating a portion of the bill rate after covering your pay and benefits. Some agencies may have larger overhead costs or simply choose to retain more profit, resulting in lower pay and benefits for you. In contrast, other agencies that operate on a slimmer margin might be able to offer you better pay or additional benefits.

To ensure you get the best possible pay package and a fair deal from your agency, it's essential to ask questions and ensure transparency in their breakdown of the bill rate. Comparing your pay and benefits across multiple agencies can help you find the best fit for your needs and potentially increase your overall travel nurse earnings.

Understanding Your Total Pay Package as a Travel Nurse

When considering a travel nursing contract, it's essential to understand the various components that make up your total pay package. Unlike staff nurse positions, the travel nursing pay structure often comprises several components, including hourly wages, stipends, bonuses, and even liability insurance reimbursements. Travel nursing companies work with healthcare facilities to determine the bill rate for each nursing position - a figure that encompasses a travel nurse's wages, benefits, and vendor management fee paid to the agency.

To fully comprehend your travel nursing pay package, it's crucial to break down each element, such as the base pay, travel stipend, and housing stipend. Doing so will help you make informed decisions when comparing offers from different travel nursing agencies. Furthermore, understanding your pay package will help you negotiate more effectively with travel nursing companies, ensuring that you receive a fair deal for your services.

Travel Nursing Pay: Other Forms of Compensation to Consider

Beyond base pay, travel nursing agencies offer additional compensation to make their positions attractive and competitive. Recognizing these other forms of compensation is essential when comparing travel nursing pay packages:

1. Travel Stipend: Many travel nursing contracts include a travel stipend to cover the cost of transportation to and from your assignment. This amount varies depending on the distance of the assignment and the travel nursing agencies you choose.

2. Housing Stipend: A crucial aspect of a travel nursing pay package is the housing stipend. This stipend is intended to cover the cost of temporary housing during your assignment. It's essential to verify whether this housing stipend is sufficient to cover the entire cost of accommodation in your destination city.

3. Bonuses and Incentives: Travel nursing companies may also offer bonuses and incentives, such as completion bonuses or extension bonuses, to travel nurses who fulfill their contract obligations or extend their contracts beyond the initial term. These bonuses can enhance the travel nursing pay package and should be taken into consideration when evaluating offers.

4. Liability Insurance: Some travel nursing agencies provide liability insurance coverage for their nurses. This coverage is essential for travel nurses, as liability claims can be financially devastating. Ensure to inquire whether the travel nursing company includes this insurance in their pay package or if you need to secure it independently.

Travel Nurse Housing: Options and Costs

For many travel nurses, housing is one of the most critical considerations when accepting a traveling nursing position. Typically, travel nursing agencies offer two primary housing options - agency-provided housing or a housing stipend. Travel nurses can elect to use the stipend to arrange their accommodation, or they can choose to stay in housing organized and funded by the travel nursing company.

When evaluating housing options, travel nurses should account for factors such as location, convenience, safety, and cost-efficiency. If you decide to arrange your housing, research average rental rates in the assignment's city to ensure the housing stipend is sufficient to cover accommodation costs. Keep in mind that agency-provided housing is often move-in ready and may include furniture, utilities, and other conveniences that make transitions easier.

How to Negotiate Your Travel Nursing Contract

When negotiating your travel nursing pay package, it's essential to approach the process with a thorough understanding of the various components and industry norms. The following steps can help you negotiate effectively with travel nursing companies:

1. Research and compare: Gather information on travel nursing pay packages from multiple travel nursing agencies and identify the industry's standard rates for your specialty and experience. This knowledge will empower you when negotiating your desired pay package.

2. Determine your priorities: Before entering negotiations, identify which components of the pay package are most important to you, such as the housing stipend or travel reimbursement. This clarity will allow you to focus on those areas during the negotiation process.

3. Be assertive and confident: Don't be afraid to express your desires and concerns regarding the contract. Remember that travel nursing agencies' primary goal is to ensure your satisfaction so that you remain with the company. Your assertiveness may secure you a better pay package or assignment conditions.

4. Consult a mentor or colleague: If you have connections in the travel nursing industry, seek their advice on negotiating contracts and navigating conversations with recruiters. Gaining insight from experienced travel nurses can be invaluable during the negotiation process.

Sample Breakdown of a Travel Nursing Pay Package

Here's an example of a travel nursing pay package, with amounts allocated for various pay components:

• Base Pay (Hourly Wages): $25 per hour
• Overtime Pay: $37.50 per hour (1.5 times the base pay)
• Housing Stipend: $2000 per month
• Travel Stipend: $500 upon completion of the contract
• Completion Bonus: $1000 upon contract completion
• Extension Bonus: $500 for extending the contract past the initial date
• Liability Insurance: Included in the pay package

By understanding the various components and industry norms, a travel nurse can successfully evaluate and negotiate their travel nursing contract. Comparing offers, researching housing options, and effectively communicating your needs to travel nursing companies will ensure that you secure favorable travel nursing pay and assignment conditions.

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LPN Travel Nurse Salary in the United States

How much does a lpn travel nurse make.

Licensed Practical Nurse LPN

Blue Ridge Therapy Connection - Stuart, VA

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Best-paying states for lpn travel nurse, frequently asked questions for lpn travel nurse, average lpn travel nurse pay vs. other jobs, relevant jobs of lpn travel nurse.

The Ultimate Travel Nurse Salary Guide: 4 Million+ Jobs Analyzed (February 2024)

We aggregated more than 4 million travel nursing salaries from the past 4+ years. Now we're revealing pay rates and job trends nationwide in our interactive pay explorer!

Average Pay (per week) $2,152.10 Based on 2,474,638 jobs analyzed across all travel nurse specialties , nationwide

Travel nursing by month (pay and count), best travel nursing agencies 🚀.

• Highest Paying
• Access Healthcare Staffing 20,000+ jobs $159.48 above average
• Host Healthcare 50,000+ jobs $113.16 above average
• Epic Travel Staffing (formerly Emerald Health) 50,000+ jobs $70.91 above average
• Aureus Medical Group 50,000+ jobs $67.75 above average
• MedPro Healthcare Staffing 50,000+ jobs -$6.35 below average
• TotalMed 50,000+ jobs -$16.04 below average
• Healthcare Staffing - IDR, Inc 20,000+ jobs -$54.61 below average
• Job Availability
• Aequor Healthcare 50,000+ jobs -$92.52 below average

Top Locations Nationwide

• New York 50,000+ jobs $227.14 above average
• California 50,000+ jobs $223.76 above average
• Massachusetts 50,000+ jobs $197.18 above average
• Illinois 50,000+ jobs $55.02 above average
• Ohio 50,000+ jobs $44.85 above average
• Washington 50,000+ jobs $34.93 above average
• Virginia 50,000+ jobs -$37.60 below average
• Texas 50,000+ jobs -$156.29 below average
• Pay is standarized to 36 hour per week.
• For agency and metropolitan area ratings, results are compared against average for specialty and state. Nationwide average pay used if no state is selected. Top paying agencies and metro areas with less than the median job count for the category are excluded.
• View all footnotes

Want to see how your travel nurse salary stacks up in this unpredictable travel nurse job market?

How about making sure you're getting the higher compensation you should be in our challenging career?

You're in the right place to get all your questions answered about travel nurse pay.

Welcome to our  interactive pay explorer - with auto-updates every month!

Since September 2019 , we've been continuously tracking travel nurse pay packages.

View our full history of pay insights using the toggle in the right-hand corner of any of our graphs in this article.

More than four million jobs analyzed and four years later, we're proud to bring you objective overviews on the travel RN job market you can't find anywhere else.

Get the full scoop in this ultimate guide:

How Much Do Travel Nurses Make?

• What Is An Average Travel Nurse Salary?

Why Do Travel Nurses Make So Much?

Is travel nursing worth it, get a travel nurse pay breakdown.

• The Highest Paying States for Travel Nurses
• The Highest Paying Travel Nurse Specialties
• How to Find the Highest Paying Travel Nursing Jobs

How To Find The Best Paying Travel Nurse Agencies

Do travel nurses earn more money than full-time registered nurses? Overall, definitely!

Keep in mind: Travel nurses make higher salaries on average.

Your potential average annual income will depend on demand for your nursing specialty and where you work.

The averages you see below are measured across all specialties and locations nationwide for a general comparison.

Average Travel Nurse Salary vs Staff Nurse Salary

The average hourly pay for full-time staff RN's in the U.S. is $39.05, or $1,561.92 per week, according to the most recent 2022 US Bureau of Labor Statistics registered nurse occupational outlook .

The average hourly rate for travel nurses is $64.58, or $2,324.92 per week, according to our Ultimate Travel Nurse Salary Guide in September 2023.

The average hourly wage for a travel RN is $25.53 higher than staff nurse pay, and the average salary per week is $736 more .

Extrapolating to compare the average annual salary of a staff nurse vs travel rn pay, the difference is significant, with travel nurses' average annual salary reaching upwards to $30,000 more.

We calculated the average annual salary for travel nurses for only 48 weeks a year. Travel nurses need time off to organize and move to new assignments.

In short, high demand = higher compensation.

We're all aware many healthcare facilities nationwide are experiencing "nursing shortages". Registered nurses are retiring and/or leaving the bedside altogether, a trend sped up by the pandemic.

It's estimated that by 2025 the US will have a staffing gap of 200,000-450,000 nurses . In other words, 10-20% of direct-patient care nursing jobs will be unfilled.

With nursing skills like ours in high demand, we deserve higher pay. Not to mention the inherent stress we put up with in our challenging career.

Travel nurses earn more competitive wages by having the adaptable skills necessary to fill critical staffing needs and provide meaningful patient care in a pinch with minimal to no orientation.

These critical needs are often on less desirable shifts, so preparing yourself to work night shift would open up more travel nurse job possibilities.

Healthcare facilities entice nurses with more competitive wages due to the extra hardships we take on with the lack of job stability while searching for new jobs every 13 weeks. There's also the lack of a consistent job benefits package and the inconveniences of travel costs and time.

If you're looking to get more satisfaction in your nursing career, it could definitely be worth it.

It turns out it really is better to be a travel nurse than a staff nurse. A sweeping study analyzing feedback straight from our fellow nurses confirms it.

Nurses working in travel nurse jobs are more satisfied than permanent staff nurses in key areas:

• better job satisfaction
• less work-related stress
• feeling safer on the job
• more employer support
• higher compensation

Working in a travel nurse job isn't easy, but it could elevate your bedside nursing practice and give you more control in your nursing career.

You'll have to decide if the pros outweigh the cons for yourself. The standard contract is only 13 weeks, so I recommend every nurse give it a try.

Pro tip: You should definitely take the time to research what to expect before you commit to a travel nurse job.

Understanding how travel nurses' higher wages breakdown will help you compare pay offers and spot the jobs that are worth your relocation.

Travel nurses are typically hired as contracted temporary employees of travel nursing agencies, getting paid on a weekly basis to work in a variety of healthcare facilities.

The most common travel nurse contracts offered are for hospital inpatient units in a healthcare facility. These contracts usually commit you to work:

• 12 hours/shift
• 3 shifts/week
• 36 hours/week
• 13 weeks total
• 468 work hours total per contract

Our  interactive pay explorer  above standardizes all travel nurse wage data around the average 36-hour weekly pay packages.

See A Pay Package Example

Here's an average travel nurse pay package offer for a Medical-Surgical Nurse working 36 hours/week:

• $400 M&IE (Meals & Incidental Expenses) - per Week
• $3,200 Housing Stipend - per Month
• $750 Travel Reimbursement - One Time payment
• $30 Base Rate - Hourly pay rate

It's confusing!  ¯\_(ツ)_/¯

Let's break this offer down to view your pay per week and per hour. Convert all parts of your travel nurse wages to a standardized hourly rate, then combine to calculate.

Your "M&IE" (meals & incidental expenses) payment is meant to cover your living expenses and daily (diem) meal costs on assignment.

Your housing stipend covers your temporary housing in your assignment location. Remember you should be maintaining housing in your permanent tax home, as well.

Many travel nursing offer travel reimbursements to help offset the higher cost of life on the road.

Be aware you may have more living expenses coming out of your travel nursing paycheck, based on what employment benefits package you accept:

• Taxes based on your permanent tax home rates
• Agency health insurance - health benefits can start at $20/week
• Agency 401k retirement plans

Ask your agency what other benefits they provide and how those affect your pay package.

Taxable vs Tax Free Pay

Following on from our pay example above, your travel nurse pay is made up of a taxable hourly wage and tax free income.

Notice that more than half of this pay package is tax free pay. Ka-ching!

Your tax free stipends, or "Per Diem" pay, are based on daily maximum rates set by the government.  Check  gsa.gov's Per Diem rates  for your next contract location.

Travel nurses are eligible for Per Diem tax free stipends when working away from your permanent tax home. When receiving tax free pay you MUST duplicate living/housing expenses, required per IRS rules.

This means paying fair market prices for both your accommodation at your travel nursing assignment, AND maintaining your own housing at your permanent tax home.

Many agencies also offer travel reimbursements to help you get money back you spent on travel expenses moving between assignments.

Pro tip: You can still "travel nurse" while living in your own housing at your permanent tax home. The difference is your income will be fully taxed, and you won't be eligible for the the tax free travel nursing pay.

Highest Paying States for Travel Nurses

Which states are really worth the higher cost license fees? Our map shows the highest paying states for travel nurses over the past 12 months.

To view the highest paying states averages since  September 2019 , use the toggle in the right-hand corner of any of our graphs.

These averages would include crisis rate market fluctuations.

Highest paying states for travel nurses. Standardized to 36/hour week contracts to compare data accurately.

For more specific travel nurse salary by state, see our table below with detailed pay trends and job availability.

We've included the  standard deviation . This shows you how 68% of pay offers spread above and below the average travel RN rates.  Picture a bell curve.

For example, 68% of California travel nurse salaries are $2,537.01 +/- $681.08 = pay range of $1,855.93 - $3,218.09.

The 'job count' column gives you a snapshot of each state's job availability.

Curious what the market looked like pre-COVID19?

Below is a compilation of the states that offered the higher pay from  September 2019 - March 2020 . Compare this list to our above map and table to see what difference crisis rates made.

Top 5 Highest Paying States for Travel Nurses (Pre - Covid19)

• California Consistently has the best pay and the most jobs by a long shot. Both inside and outside of the pandemic.
• New Jersey Solid opportunities for both pay and job availability.
• Washington D.C. Great income, but fewer job openings.
• Alaska Decent pay and lots of jobs, despite reputation for low rates. Current rates lower than pre-covid19.
• Connecticut Regularly pays above average with frequent job openings.

Highest Travel Nurse Salaries by Metropolitan Area

Not sure which areas of the country pay great for travel nurses?

We've got a summary here to get you started. Get even more location-specific data on high paying opportunities using our interactive pay explorer .

Top 5 Highest Travel Nurse Salaries by Metropolitan Area

Go after high pay AND lots of job openings in these locations:

• California Holds 9 of our top 10 spots for highest-paying metro areas
• East Coast New York City-Newark, Boston, Philadelphia, Washington DC
• Pacific Northwest Seattle-Tacoma, Portland
• Midwest St Louis, Chicago
• Arizona Phoenix, Tuscon

Pro Tip: Investing in a California license is worth your time and money if you're looking for LOTS of high-paying job options.

Highest Paying Travel Nurse Specialties

Feast your eyes on the largest travel nursing specialty comparison available including more than  130 specialties . Our interactive table shows nationwide pay averages including  standard deviation  for you to get an accurate overview of the highest paying specialties.

We removed specialties with very low job counts and supervisory roles. This keeps our data relevant to the travel nursing specialties with high pay AND regular job availability.

For a different view, we've got an interactive bubble chart displaying the highest paying travel nurse specialties by their job availability. Hover over the bubbles to identify the specialties.

Not all nursing specialties have a regular high need for travel nurses. For example, RN's in Electrophysiology Lab (EP Lab) regularly have higher pay offerings, but don't have the plentiful job options that ICU or L&D nurses have.

Pro tip: If you aspire to work consistently as a travel nurse, gain experience in a specialty with higher job availability.

I repeat: Higher demand = Higher compensation.

How To Find the Highest Paying Travel Nursing Jobs

How can you cut through the lowball offers to find and land the best paying travel nurse salaries? We started StellarNurse to help you.

After analyzing the market for 4+ years, here's our best advice:

• Use our interactive pay explorer to check pay trends, job availability and best agencies for your specialty
• Check out the newest & highest-paying travel nursing jobs to get an objective overview on your best current opportunities
• Message agencies anonymously on our StellarNurse jobs marketplace, focus on agencies that pay best and have lots of jobs for your specialty
• Keep current state licenses for the locations that have your specialty's best pay and highest job availability
• Breakdown pay packages to weekly or hourly income to accurately compare job offers
• Prioritize high pay - above personal convenience, best locations, nicest recruiter or agency loyalty
• Move fast for Crisis or Rapid Response rate offers

In a nutshell, stay flexible. The best offers are competitive and often need help fast. Be ready to adjust plans quickly, coordinate with a new agency or arrange travel to an unexpected location.

Bonus tip: If you like your agency, tell fellow travel nurses. Make an easy $500-$1,000. Every agency offers referral bonuses if a nurse you referred works with them too.

With more than 500 agencies posting travel nursing jobs daily it’s overwhelming to find which ones might be the best travel nurse companies for you.

After analyzing 4 million jobs over the past 4 years, we’ve organized our data to help you make informed decisions on which agencies to prioritize contacting first.

Find the best paying travel nurse agencies for your specialty and preferred locations. Use the filters to see which agencies have the most jobs available.

Refer back to our interactive pay explorer for in-depth pay trends on the best travel nursing agencies for your specialty and locations.

StellarNurse answers three important questions you should consider in your travel nurse agency choices.

Which travel nurse agencies have:

• The highest paying jobs for your specialty?
• The most jobs available for your locations?
• The benefits you’re looking for?

More questions you should consider when choosing a travel nurse agency are:

• What sets this agency apart?
• What agency resources are available if you have issues?
• How responsive is this agency?

Furthermore, find unbiased reviews to guide your choices.

Since I prefer to read reviews directly from my fellow nurses, here's where I look:

Bonus tip: You can message recruiters anonymously on the StellarNurse jobs marketplace totally risk-free. Get all your questions answered before giving up your contact info.

Our Data Sources

All our data is publicly available on the named travel nursing agency's website or Google jobs listings.

Methodology

We'll be publishing more technical details on our GitHub in the near future.

Dropping the Mic 🖐🎤

We can't wait to hear your success stories - Tell us how our travel nurse salary interactive pay explorer has helped you.

Did we miss any questions you have about finding how much travel nurses can make?

Connect with us on Instagram and Facebook so we can add your requests to future updates.

Share with your registered nurse friends so they can see their earning potential too!

Your days of being underpaid are over.

Bring evidence-based practice to your job search. Land the highest paying travel nursing jobs based on objective market overviews.

Travel Nurse Pay & Benefits

Understanding Travel Nurse Salary and Your Benefits Package

How much do travel nurses make?

There are many factors to consider when talking about how much travel nurses get paid, including:

When looking to optimize pay, it’s important to understand that pay packages differ based on specialty and location. For instance, a travel L&D nurse in California will make a different amount than a travel med-surg nurse in Kentucky.

Many travel nurses bounce around between states — sometimes even between specialties — and will be paid differently from assignment to assignment. You may also be eligible for housing, meal and incidental stipends to reimburse you for actual expenses incurred while on assignment. Your recruiter will discuss all these details with you during your search. Your recruiter will work diligently to find you positions that meet your financial goals. Keep in mind that flexibility during your job search with location, shift and other factors usually results in the potential of higher paying opportunities.

Log in and view pay packages and facility information for all jobs.

Travel Nursing Benefits with Aya

You can enroll and contribute to your 401k on the first of the month following eligibility, which is working 4 consecutive months or one year from your original hire date (with at least 1,000 hours worked). After a year (with at least 1,000 hours worked) you’re eligible for matching!

Medical Plan

A comprehensive medical, dental and vision plan from the first day you start an assignment with Aya Healthcare. You also have the option to add a spouse and/or dependents to your plan!

Sick Pay While on Assignment

You’ll start accruing sick time on the first day of your assignment and earn 1 hour for every 30 hours worked which you can start to use after 90 days.

Perks & Discounts

Wellness and fitness programs (like free virtual meditation and yoga) employee assistance programs (including clinical escalation if your work environment could be improved) and so much more.

Aya Scholars Program

This is the industry’s only clinical ladder program for travel nurses. In exchange for dedication to professional development, Aya Scholars candidates may be eligible for reimbursements for tuition and a specialty certification exam.

Where can I make the most money as a travel nurse?

Like we mentioned earlier, quite a few factors affect your pay, including specialty and location. But like with any job, you need to consider more than just pay. When evaluating an assignment, you should also consider the cost of living in the area. You can rely on your recruiter and the rest of your Aya Healthcare team for valuable advice to help you make the best career choice for you.

Privacy Overview

Nursing homes must meet minimum federal staffing levels under Biden rule

Most U.S. nursing homes will need to add staffing under a federal rule announced Monday that for the first time sets minimum staffing ratios nationwide for homes that care for elderly and disabled people.

The rule, announced Monday by Vice President Kamala Harris, mandates that nursing homes meet minimum staffing requirements for registered nurses and nurse aides. The rule is intended to limit cases of resident neglect or delays in care, a lingering issue that was exposed when more than 200,000 nursing home residents and staff died from COVID-19 in the first two years of the pandemic.

Experts call the rule a significant step toward bolstering nursing home quality and safety.  

“This is the most important nursing home reform in decades,” said David Grabowski, a professor of health care policy at Harvard Medical School. “We need more staff in nursing homes. This is a big development in terms of setting a floor such that nursing homes can’t grossly understaff facilities.”

Mark Parkinson, president and CEO of the nursing home industry group American Health Care Association, blasted the rule as "unconscionable" given the nation's nursing shortage.

"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," Parkinson said in a statement. "This unfunded mandate doesn’t magically solve the nursing crisis."

The White House said in a fact sheet the new rule requires all nursing homes receiving federal funding through Medicare and Medicaid to provide staffing that is the equivalent of nearly 3.5 hours of daily care for each resident. The rule also requires that nursing homes have registered nurses on duty 24 hours, seven days a week to "provide skilled nursing, which will further improve nursing home safety."

On average, a nursing home with 100 residents would have two to three registered nurses and at least 10 nurse assistants on duty for each shift around the clock. Officials said this level of staffing is necessary to provide safe care with good outcomes for vulnerable residents.

Xavier Becerra, U.S. Secretary of Health and Human Services, told USA TODAY on Monday these staffing requirements represent the minimum level of care for more than 1.2 million Americans in federally certified nursing homes.

"If you're going to represent yourself to be a nursing home, you should have a nurse available to care for my loved one that I'm about to put in your facility," Becerra said. "We insist that the care that you're going to provide must be quality."

It's a level of care any family member would expect, he said.

The Biden administration said the rule will be implemented in phases to give nursing homes, especially those in rural communities, time to hire the additional workers. Nursing homes must complete an assessment gauging the day-to-day needs of residents within 90 days of the rule being finalized. The minimum staffing levels will be phased in over two to three years.

Nursing homes in communities facing a workforce shortage will get "limited, temporary exemptions" to meet the registered nurse requirement and overall staffing ratios, the White House said.

Federal and academic researchers have long established staffing levels as the best predictor of quality nursing home care. However, the Centers for Medicare & Medicaid Services, which regulates nursing homes that take Medicare and Medicaid funding, has never required a specific number of nurses and aides. The agency has only made recommendations which few facilities followed.

In a related rule also announced Monday, the Biden administration seeks to bolster home care for seniors and disabled residents on Medicaid, the federal health program for low-income populations. The rule requires companies that provide home care services spend a minimum of 80% of Medicaid payments on workers' wages.

The Biden administration said higher wages for home health care workers would reduce turnover and lead to higher quality home care for the elderly and disabled.

Home health care workers "can sometimes find a better paying job going to flip burgers than to offer your loved one the care that he or she needs," Becerra said. "We need to do more."

The home care rule, which is similar to the rule on nursing home staffing ratios, would allow states to account for "unique experiences that small home care providers and providers in rural areas face" in meeting such requirements, the White House said.

A  USA TODAY investigation  found that although nursing homes have submitted daily staffing data to federal officials for years, they have rarely been punished for violating the existing guidelines and rules. 

Such penalties have been unusual even at facilities where inspectors noted low staffing in the course of investigating avoidable deaths, and people who'd suffered broken bones, spent days without help getting out of bed or hours sitting in feces, among other violations. Fines for such violations have been even rarer. 

Contributing: Jayme Fraser

The independent source for health policy research, polling, and news.

With Current Staffing Levels, About 1 in 5 Nursing Facilities Would Meet Fully-Implemented Minimum Staffing Standards in the Final Rule

Priya Chidambaram , Alice Burns , Tricia Neuman , and Robin Rudowitz Published: Apr 22, 2024

Editor’s Note: This brief was updated on April 24th, 2024 to reflect a CMS statement that the final requirements of the rule must be met by May 2029 for rural facilities. A previous version of this brief cited May 2028, which reflected the date written into the text of the regulation.

On April 22, 2024, the Centers for Medicare and Medicaid Services (CMS) released a highly-anticipated final rule that creates new requirements for nurse staffing levels in nursing facilities, settings that provide medical and personal care services for 1.2 million Americans , and for which the adequacy of staffing has been a longstanding issue. CMS received nearly 50,000 comments on the proposed rule, ranging from comments that strongly supported the proposed standards to those that opposed them. Among those comments, the nursing home industry suggested the rule was too onerous, given staffing shortages and costs, and could lead to nursing facility closures, while resident and family advocates suggested the proposed standards were too weak to address quality concerns.

In the final rule, CMS adopted staffing standards that are mostly similar to the staffing requirements in the proposed rule. Requirements will take effect in different phases. When fully implemented for all facilities, nursing facilities will be required to meet minimum nurse staffing levels of 3.48 hours per resident day (HPRD), including 0.55 registered nurse (RN) and 2.45 nurse aide HPRD. Additionally, they will be required to have an RN on duty 24 hours a day, 7 days a week (24/7). By May 2027, prior to full implementation, the final rule requires nursing facilities to have an RN on duty 24/7 and at least 3.48 HPRD of total nurse staffing hours irrespective of staff type, without the more specific RN and nurse aide requirements that take effect when the rule is fully implemented. Timelines for meeting the interim and final requirements will differ for urban (10,400 facilities, or 73% of facilities) and rural facilities (4,000 facilities, or 27% of facilities). The interim requirements must be met by May 2026 for urban facilities and May 2027 for rural facilities. The final requirements must be met by May 2027 for urban facilities and May 2029 for rural facilities.

This analysis uses the most recent publicly-available data to examine the percentage of nursing facilities that currently meet the minimum staffing requirements in the final rule, which phases in beginning in May 2026 for some facilities. Specifically, this analysis calculates the share of facilities that currently meet the overall requirement of 3.48 HPRD (regardless of staff type) and the share that meet the fully implemented, more specific staffing standards (HRPDs of 3.48 overall, 0.55 for RNs, and 2.45 for nurse aides). This analysis uses Nursing Home Compare data from March 2024, which includes 14,403 nursing facilities (97% of all facilities, serving 1.18 million or 98% of all residents), and reflects staffing levels from July to September 2023. Due to data limitations, this analysis does not look at the 24/7 RN requirement. See Methods for more information.

KFF estimates that 19% of nursing facilities would meet the minimum HPRD staffing standards under full implementation of the final rule with their current staffing levels (Figure 1). Nearly 60% of facilities would meet the interim requirement of an overall requirement of 3.48 HPRD, but fewer facilities would meet the RN and nurse aide provisions that are required when the rule is fully implemented (49% and 30% respectively; data not shown).

The final rule also includes new reporting and assessment requirements and the process by which facilities may qualify for an exemption from the minimum staffing provisions. The final rule also indicates that CMS will release additional details later this year on how the $75 million investment in a nursing home staffing campaign will be structured. As noted in the proposed rule, CMS aims to balance the goal of establishing stronger staffing requirements against the practicalities of implementation and costs.

The analysis does not evaluate facilities’ ability to comply with other requirements in the final rule, including the requirement to always have a registered nurse on duty 24/7 or the ability to meet the new reporting and assessment requirements due to data limitations (see Methods ). The analysis also does not estimate which facilities would qualify for an exemption or how staffing levels will change between now and when the staffing standards take effect.

A forthcoming analysis will look at the share of facilities that currently meet the new standards across a variety of dimensions, including ownership, state, and urban or rural location.

This analysis uses Nursing Home Compare as of March 2024 and reflects staffing levels from July to September 2023. Nursing Home Compare is a publicly available dataset that provides a snapshot of information on quality of care and key characteristics for approximately 14,900 Medicare and/or Medicaid-certified nursing facilities. This analysis drops about 3% of nursing facilities, including the facilities in Guam and Puerto Rico and nursing facilities for which there was not staffing data available for the fourth quarter of 2023, for a total analytic sample of 14,403 facilities. The number of facilities identified in this analysis as meeting/not meeting requirements may differ from CMS’ estimates due to different years and quarters of data used for estimates.

The Office of Management and Budget’s (OMB) delineation of metropolitan and micropolitan statistical areas were used to designate rural and urban areas. Urban and rural facilities have different timelines to come into compliance with the rule, which this analysis does not take into account. This analysis reflects compliance rates if the HPRD requirements were in effect now for all facilities.

Due to the limitations of publicly available data, this analysis does not look at facilities that meet the requirement to have an RN on staff 24 hours a day, seven days a week (24/7). Nursing home staffing data is calculated from the Payroll Based Journal (PBJ), which includes data on the total number of RN hours worked per day at a facility, but no data on the timing of shifts. This limits our understanding of whether shifts were worked simultaneously by multiple employees (possibly not fulfilling the 24-hour requirement) or whether those hours were spread out over a 24-hour period (fulfilling the 24-hour requirement).

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Fact Sheet: Vice President Harris Announces Historic Advancements in Long-Term Care to Support the Care   Economy

Actions are the latest in a series of steps the Biden-Harris Administration has taken to improve safety, provide support for care workers and family caregivers, and to expand access to affordable, high-quality care

Everyone deserves to be treated with dignity and respect and to have access to quality care. That’s why, today, Vice President Harris is announcing two landmark final rules that fulfill the President’s commitment to safety in care, improving access to long-term care and the quality of caregiving jobs. Ensuring that all Americans, including older Americans and people with disabilities, have access to care – including home-based care – that is safe, reliable, and of high quality is an important part of the President’s agenda and a part of the President’s broader commitment to care. Today’s announcements deliver on the President’s promise in the State of the Union to crack down on nursing homes that endanger resident safety as well as his historic Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers , which included the most comprehensive set of executive actions any President has taken to improve care for millions of seniors and people with disabilities while supporting care workers and family caregivers.

Cracking Down on Inadequate Nursing Home Care

Medicare and Medicaid pay billions of dollars per year to ensure that 1.2 million Americans that receive care in nursing homes are cared for, yet too many nursing homes chronically understaff their facilities, leading to sub-standard or unsafe care. 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. Understaffing can also have a disproportionate impact on women and people of color who make up a large proportion of the nursing home workforce because, without sufficient support, these dedicated workers can’t provide the care they know the residents deserve. In his 2022 State of the Union address, President Biden pledged that he would “protect seniors’ lives and life savings by cracking down on nursing homes that commit fraud, endanger patient safety, or prescribe drugs they don’t need.”

The Nursing Home Minimum Staffing Rule finalized today will require all nursing homes that receive federal funding through Medicare and Medicaid to have 3.48 hours per resident per day of total staffing, including a defined number from both registered nurses (0.55 hours per resident per day) and nurse aides (2.45 per resident per day). This means a facility with 100 residents would need at least two or three RNs and at least ten or eleven nurse aides as well as two additional nurse staff (which could be registered nurses, licensed professional nurses, or nurse aides) per shift to meet the minimum staffing standards. Many facilities would need to staff at a higher level based on their residents’ needs. It will also require facilities to have a registered nurse onsite 24 hours a day, seven days a week, to provide skilled nursing care, which will further improve nursing home safety. Adequate staffing is proven to be one of the measures most strongly associated with safety and good care outcomes.

To make sure nursing homes have the time they need to hire necessary staff, the requirements of this rule will be introduced in phases, with longer timeframes for rural communities. Limited, temporary exemptions will be available for both the 24/7 registered nurse requirement and the underlying staffing standards for nursing homes in workforce shortage areas that demonstrate a good faith effort to hire.

Strong transparency measures will ensure nursing home residents and their families are aware when a nursing home is using an exemption.

This rule will not only benefit residents and their families, it will also ensure that workers aren’t stretched too thin by having inadequate staff on site, which is currently a common reason for worker burnout and turnover. Workers who are on the frontlines interacting with residents and understanding their needs will also be given a voice in developing staffing plans for nursing homes. The Biden-Harris Administration also continues to invest in expanding the pipeline of nursing workers and other care workers, who are so essential to our economy, including through funding from the U.S. Department of Health and Human Services.

Improving Access to Home Care and the Quality of Home Care Jobs

Over seven million seniors and people with disabilities, alongside their families, rely on home and community-based services to provide for long-term care needs in their own homes and communities. This critical care is provided by a dedicated home care workforce, made up disproportionately by women of color, that often struggles to make ends meet due to low wages and few benefits. At the same time, home care is still very inaccessible for many Medicaid enrollees, with more than threequarters of home care providers not accepting new clients, leaving hundreds of thousands of older Americans and Americans with disabilities on waiting lists or struggling to afford the care they need.

The “Ensuring Access to Medicaid Services” final rule, finalized today, will help improve access to home care services as well as improve the quality caregiving jobs through its new provisions for home care. Specifically, the rule will ensure adequate compensation for home care workers by requiring that at least 80 percent of Medicaid payments for home care services go to workers’ wages. This policy would also allow states to take into account the unique experiences that small home care providers and providers in rural areas face while ensuring their employees receive their fair share of Medicaid payments and continued training as well as the delivery of quality care. Higher wages will likely reduce turnover, leading to higher quality of care for older adults and people with disabilities across the nation, as studies have shown. States will also be required to be more transparent in how much they pay for home care services and how they set those rates, increasing the accountability for home care providers. Finally, states will have to create a home care rate-setting advisory group made up of beneficiaries, home care workers and other key stakeholders to advise and consult on provider payment rates and direct compensation for direct care workers.

Strong Record on Improving Access to Care and Supporting Caregivers

Today’s new final rules are in addition to an already impressive track record on delivering on the President’s Executive Order on Care. Over the last year, the Biden-Harris Administration has:

• Increased pay for care workers, including by proposing a rule to gradually increase pay for Head Start teachers by about $10,000, to reach parity with the salaries of public preschool teachers.
• Cut child care costs for low-income families by finalizing a rule that will reduce or eliminate copayments for more than 100,000 working families, and lowering the cost of care for lower earning service members, thereby reducing the cost of child care for nearly two-thirds of children receiving care on military bases. Military families earning $45,000 would see a 34% decrease in the amount they pay for child care.
• Supported family caregivers by making it easier for family caregivers to access Medicare beneficiary information and provide more support as they prepare for their loved ones to be discharged from the hospital. The Administration has also expanded access to mental health services for tens of thousands of family caregivers who are helping veterans.

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Nursing home industry rebukes new federal rule on minimum staffing requirements

Kai McNamee

Sarah Handel

Scott Detrow

NPR's Scott Detrow talks with American Health Care Association's CEO Mark Parkinson about the new rule that establishes staffing minimums at nursing homes that receive Medicare and Medicaid funding.

SCOTT DETROW, HOST:

On Monday the Biden administration finalized a rule that establishes staffing minimums at nursing homes that receive Medicare and Medicaid funding. Xavier Becerra, Secretary of the Department of Health and Human Services, told NPR last fall that the rule is meant to define standards for the industry.

(SOUNDBITE OF ARCHIVED NPR BROADCAST)

XAVIER BECERRA: It's been the Wild, Wild West when it comes to quality and accountability at nursing homes throughout the country. What we're simply saying is we don't want Wild, Wild West when we send our loved ones.

DETROW: The rule has been met with backlash, including from the American Health Care Association, which represents the nursing home industry. In a statement, President and CEO Mark Parkinson called it, quote, "an unreasonable standard that only threatens to shut down more nursing homes." Mark Parkinson joins me now. Welcome to ALL THINGS CONSIDERED.

MARK PARKINSON: Good to be here.

DETROW: So, you know, according to the White House - and I'll just read a quote here from their announcement of this. "Under the new rules, the average nursing home, which has around a hundred residents, would need to have at least two RNs working each day and at least 10 to 11 nurse aides." In addition to that, nursing homes are going to have several years to comply with this. There is an application for hardship exemptions. Can you walk me through why that is unreasonable in your point of view? What is your concern here?

PARKINSON: There is a shortage of nurses across the country, but it is the most acute in skilled nursing facilities. The administration has done nothing to help us with this staffing crisis. And then to add on top of that, a requirement that we need to hire an additional 120,000 nurses - which is what the number is - would make it impossible. So it - we're not against more staffing. Believe me. Every nursing home in the country out there right now is hustling and advertising to get more staff. But what we are against is an impossible policy that, when it is enforced, will cause hundreds and possibly thousands of nursing homes to close.

DETROW: I just want to clarify right now. Is your point of view mostly that this is impossible to achieve or that the increased staff is not necessarily needed or wouldn't necessarily make care better? Which one is it, or is it a bit of both?

PARKINSON: We believe that more staff makes care better. The reason we're against it is because it's impossible to achieve. It is not possible to get these nurses. They're not out there. And the proposal is not paid for.

DETROW: The Kaiser Family Foundation did a study on this, found that about 80% of all nursing homes would have to hire more people to meet the new standard. Does that feel right to you?

PARKINSON: We think it's probably more like 95%. So it's somewhere 80 and 95% of all the facilities are unable to meet the requirement right now.

DETROW: Look. Big picture, NPR and so many other news organizations have reported on conditions in nursing homes. And there's been a lot of concerns - you know, residents experiencing bed sores, dehydration, malnourishment, falls, other things. We all know how hard COVID hit the nursing home community. We've been talking a lot about the staffing here. What are the big-picture solutions besides staffing - besides increasing staffing from your point of view?

PARKINSON: I think the big-picture solution is really the course that we were headed on before the pandemic, which is to look at the quality measures that are out there, trying to figure out what are the things that really matter in terms of the care that's being provided in a facility. And you mentioned some of them - falls, return to home, pain that a resident is experiencing, person-centered care, holding buildings accountable that aren't doing well on those metrics, weeding out the poor providers and really promoting and uplifting the good providers. And we've been on a good momentum to do that. If you look at the 20 quality measures that are out there on nursing homes, they have improved over the years.

Now, we definitely had a setback with COVID, which, you know, hopefully is a once-in-a-lifetime type experience. But now that that's behind us, the sector is really recommitted to a data-driven approach, not just, you know, making decisions based on anecdotes but a really data-driven approach to make sure that we continue to improve those quality measures.

DETROW: That's Mark Parkinson, President and CEO of the American Healthcare Association. Thank you so much.

PARKINSON: Thank you for having me.

Copyright © 2024 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by an NPR contractor. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

Massachusetts commits $1 billion to move thousands out of nursing homes in wake of lawsuit settlement

Nursing home residents should find it dramatically easier to return to their communities after Massachusetts committed to spending $1 billion over the next eight years for new housing and community support for people seeking to leave long-term care facilities.

The commitment was part of a settlement in a lawsuit filed in US District Court by the Massachusetts Senior Action Council and seven nursing home residents who wanted to return to their communities but could not find housing to accommodate them. The plaintiffs had physical or mental disabilities but could live outside a nursing home setting with some supports, said Steven Schwartz, a lawyer from the Center for Public Representation and one of the attorneys for the plaintiffs. He estimated that a majority of the state’s 21,000 Medicaid recipients receiving long-term care at nursing facilities would be eligible to leave for community settings.

“Our very value as individual citizens [comes] from a set of community activities, working, voting, going to school, going to a baseball game,” Schwartz said in an interview. “None of these things we think of as valued experiences in our life are available living in nursing homes.”

The settlement would apply to all nursing home residents on Medicaid, who make up the vast majority of those in long-term residential care, Schwartz said.

Massachusetts officials framed the settlement agreement as a next step in the state’s commitment to more independent living.

“Whether that means helping people find and access appropriate community-based care or housing opportunities, we want everyone to feel empowered in making their own most informed decision,” Kate Walsh, the state’s Secretary of Health and Human Services, said in a statement.

The state also agreed to pay $1.8 million for the plaintiffs’ legal fees.

The state’s obligations will be paid for through federal funds and money appropriated through the Legislature, according to the agreement.

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The settlement is expected to receive final approval from the court this summer, Schwartz said.

In 2023, almost 75 percent of the state’s spending for long-term services and supports went toward care in people’s homes or community settings rather than in residential institutions, the Executive Office of Health and Human Services reported.

In a statement last week, one of the plaintiffs — a US Army veteran with diabetes, epilepsy, and who had a stroke in 2020 — described how painful it was to shift from independent living to a nursing home.

“For me, living in a nursing home is like living under martial law,” said Richard Caouette, who lives at a nursing facility in Worcester. “I am determined to return to the community and pray the Agreement will get me a new home so I can leave here.”

The reforms should allow at least 2,400 Medicaid recipients in nursing homes to transition to different residences over eight years, the state Executive Office of Health and Human Services said. The state agreed to use an array of tools, including subsidized housing, expanded access to 24-hour residential care, and $100,000 dedicated to significant accessibility modifications to at least 120 residences, allowing some people to return to their homes.

In a key condition of the settlement, the state also committed to an education program to inform nursing home residents of their expanded living options and help those who want to move plan for their transitions. The plan would bring transition liaisons to nursing homes weekly to meet with residents and provide visits to alternative living arrangements in the community, giving them in-person experience with other residential options. Residents would have access to culturally sensitive consultations in their native language.

“We have really tried to elevate the provisions in the settlement agreement to impact minority communities, particularly Black and brown communities,” Schwartz said.

He described the settlement as a potential paradigm shift.

“It’s revolutionary,” he said.

The settlement is unique in the nation, he said, because it applies to anyone living in a nursing facility. Similar settlements, including some in Massachusetts, have expanded living options, but only for people with specific conditions or diagnoses.

The suit, Marsters vs. Healey, was filed in October 2022 and argued Massachusetts was in violation of a 1999 US Supreme Court ruling that determined it was discriminatory for states to not provide support and services for people who want to live outside institutions like nursing homes.

Society has shifted away from nursing care for years, Schwartz said. Technological advances have made medical care and support outside an institution more available, and governments have increasingly dedicated more money to alternative housing options.

But the state’s 349 nursing facilities provide a key resource in the state, said Tara Gregorio, president of the Massachusetts Senior Care Association, which represents nursing homes and other institutions that deliver care to seniors and those with disabilities. She declined to say what the impact of the settlement could be on the nursing home industry but estimated the demand for long-term residential care would grow over the next 10 years due to a projected 40 percent increase in the population of people 85 and older. Some of the seniors who need long-term nursing care would not be able to live in community settings or may not want to.

“It is critical that these core services be fully funded to ensure the safety and well-being of our residents and to allow us to continue to invest in and grow our dedicated workforce,” she said in an emailed statement.

Of the seven people who filed the suit less than two years ago, one, John Simmons, has died. Another was able to find housing in the community and two more are in the process of transitioning out of nursing homes, Schwartz said. Another three want to leave their nursing homes.

“For the past two years, I have been confined to a nursing facility where I can’t do anything for myself,” said Lorraine Simpson, a plaintiff in the process of leaving a Worcester nursing facility, in a statement. “I can’t wait to take care of my own home, spend time with my family, and cook for them again.”

Jason Laughlin can be reached at [email protected] . Follow him @jasmlaughlin .

Biden administration imposes first-ever staff minimum for nursing homes

The senior care industry lobbied furiously against the new standard, which will require a registered nurse on site at all times.

The Biden administration set a first-ever minimum staffing rule for nursing homes Monday, making good on the president’s promise more than two years ago to seek improvements in care for the nation’s 1.2 million nursing home residents.

The final rule, proposed in September, requires a registered nurse to be on-site in every skilled nursing facility for 24 hours a day, seven days a week. It mandates enough staff to provide every resident with at least 3.48 hours of care each day. And it beefs up rules for assessing the care needs of every resident, which will boost staff numbers above the minimum to care for sicker residents.

For a facility with 100 residents, it translates to a minimum of two or three registered nurses and at least 10 or 11 nurse aides per shift, as well as two additional staffers who could be nurses or aides per shift, according to the administration’s interpretation of its new formula. Set to phase in over the next few years, the mandate will replace the current vague standard that gives operators wide latitude on how to staff their facilities.

The nation’s 15,000 nursing homes are regulated by the federal government, which pays for the majority of stays through the Medicaid and Medicare federal insurance programs. Neglect and abuse have been concerns for decades, but the crisis of care reached a peak during the pandemic, when more than 160,000 nursing home residents died of covid-19.

While the administration has said the rule will improve care, industry lobbyists have said it’s unworkable, with staffing goals that will be impossible to achieve because of a shortage of workers.

The administration received 47,000 public comments on the rule since it was proposed last September. They included observations of people lying in their own filth for hours, not being fed appropriately and being left on the floor too long after falling, Secretary of Health and Human Services Xavier Becerra said in an interview Monday.

“These are the kinds of things that drive nightmares in the minds of family members,” he said. “If you’re claiming that you can’t find nurses, then explain to me how you’re running a nursing home.”

An industry study last year, in response to the proposal, said nearly all nursing homes would not meet the new standards and would be required to hire more people. Nursing homes would need to hire more than 100,000 additional workers: 80,077 nurse aides and 22,077 registered nurses, the study said.

The pandemic exacerbated staffing shortages in nursing homes. Poor wages and grueling working conditions put large amounts of stress on a low-wage workforce, which is made up mostly of women, minorities and immigrants.

An independent study released last year by KFF, a nonprofit group specializing in health care, said around 80 percent of facilities would need to hire more staff to meet the new requirements.

While the government said the cost of the plan would be $4.4 billion per year by the third year of adoption, industry groups said the number was closer to $7 billion.

“It is unconscionable that the Administration is finalizing this rule given our nation’s changing demographics and growing caregiver shortage,” Mark Parkinson, president and CEO of the American Health Care Association, the top lobbying group for the nursing home industry, said Monday in response to the administration’s release of the final proposal. “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 industry has warned that rural facilities may be forced to close if they can’t meet the requirements.

In a 71-bed facility in Pipestone, Minn., the operator, a large nonprofit system called Good Samaritan Society, would have to hire five more registered nurses and five certified nurse assistants to its total roster of staff, said Nate Schema, Good Samaritan’s president and CEO. That’s in a community of just 4,100 people.

“It’s unrealistic,” he said. “This unfunded mandate just doesn’t make sense, and it’s going to create additional access challenges for residents and families that we service.”

On Capitol Hill, Sen. Deb Fischer (R-Neb.) sponsored a bill that would prevent the administration from imposing the rule, but it did not advance after receiving insufficient support in the Democratic-controlled chamber.

The Democratic co-sponsor, Sen. Jon Tester (Mont.), warned that some rural nursing homes may close in his state. “I have serious concerns that this burdensome staffing requirement will be unworkable for rural nursing homes,” he said in a statement.

Nursing-home owners in urban areas will have two years to comply with the rules, while rural operators will have three years. Operators in rural areas without enough workers can qualify for hardship exemptions, the administration said.

The new requirement will replace a rule that merely required an operator to maintain a staff level “sufficient” to assure the safety and well-being of residents. Facilities will be required to have enough registered nurses to provide 0.55 hours of care per resident per day and enough nurse aides to provide 2.45 hours of care. The additional 0.48 hours of care can be provided by a registered nurse, a licensed practical nurse or a care aide, under the rule.

The rule also increases guidelines for annual assessments of residents’ care needs, which will dictate to what degree operators must exceed the new hourly requirements.

“They’re acknowledging this is a minimum. This is the floor, not the ceiling,” said Toby Edelman, senior policy attorney with the Center for Medicare Advocacy, which has fought for stronger quality and staffing requirements.

Advocates for the health and safety of nursing home residents say operators could attract workers if they pay more. Front-line workers in nursing homes are paid around $17 an hour, according to PHI, a nonprofit that tracks wage data for elder-care workers.

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Nurses in England took an average of one week off sick for stress last year, data shows

Chronic workforce shortages have put nursing staff under unbearable pressure, says union chief

Nurses in England took an average of a week off sick last year because of stress, anxiety or depression, NHS figures reveal.

The disclosure has prompted concern that the intense strains nurses face in their jobs, including low pay and understaffing, are damaging their mental health and causing many to quit.

Nurses and health visitors took a total of 1,675,275 days off sick during 2023 as a result of stress and similar conditions, NHS England data showed.

That means that each of England’s 352,125 members of both professions missed an average of 4.95 days at work for that reason, according to a Royal College of Nursing analysis of the figures.

“Dangerous stress levels have become normalised inside an NHS which is unable to cope with demand,” said Prof Pat Cullen, the RCN’s general secretary and chief executive.

“Chronic workforce shortages are putting nurses under unbearable pressure. Nursing staff … are running on empty. Government and NHS leaders need to stop normalising poor mental health among staff.”

In all, nurses and health visitors took 6.9m days off sick last year, but the 1.68m days they missed owing to stress, anxiety and depression were the single biggest source of illness. They comprised 24.3% of the total, up from 21% the year before. Colds and flu were the second largest reason for sick days last year, at 12%.

“These are sobering findings,” said Prof Alison Leary, the chair of healthcare and workforce modelling at London South Bank University. She highlighted that 2023 was the year that – for the first time – nurses who left the NHS cited work-life balance as the reason rather than retirement, according to other NHS data.

Many nurses are experiencing “moral distress”, Leary added. “It exists when a nurse can see what care the patient needs but doesn’t have the resources to provide it.

“Nurses generally are committed people and come to work to do a good job, [but] extreme workloads mean that they cannot do all of their work and this causes them distress,” she said.

Nurse shortages are widespread, with 34,709 vacancies in England. A hospital nurse in the West Midlands told the RCN that the “lack of staff combined with demand for services is a constant worry. It is causing stress and a lack of sleep. I feel low and let down by the system.”

Another nurse said: “[I am] so stressed and anxious about lack of income and financial pressures that my mental health has seriously deteriorated to the point of taking long-term sick leave for the second time in two years.”

The intense pressures of their jobs lead to many nurses and midwives quitting, especially early in their careers. One in eight nursing students drop out during their training, one in nine midwives do not join the profession after they graduate and one in five nurses leave within two years of joining the NHS, according to research published by the Nuffield Trust health thinktank in September.

An independent analysis commissioned by the RCN and published last month found that nurses’ pay fell by an average of nearly 25% between 2010-11 and 2023-24.

The RCN has said their pay levels mean many nurses have been struggling to cope with the soaring inflation that has hit households in recent years.

During 2022-23, more than 12,000 UK-registered nurses applied for a certificate of current professional status, which allows them to work in other countries such as the US and Australia, where nursing pay is higher. That was more than double the number who did so the year before and four times higher than in 2018-19.

The Department of Health and Social Care said: “The most recent NHS staff survey shows improvement in morale and staff experience. And there are now record numbers of doctors and nurses working in the health service.

“NHS England has published a strategy to grow occupational health and wellbeing support, and the NHS long-term workforce plan will retain even more staff, meaning there are up to 190,000 more nurses by 2036-37.”

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