The National Imperative to Improve Nursing Home Quality Honoring Our Commitment to Residents, Families, and Staff (2022) / Chapter Skim
Currently Skimming:
5 The Nursing Home Workforce
5 The Nursing Home Workforce
Pages 221-302
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 221... ...
. Federal guidelines dictate that facilities must "have sufficient staff to assure the safety of residents and attain or maintain the highest feasible level of physical, mental, and psychosocial well-being of each resident."1 However, adequate staffing in nursing homes has been difficult to achieve for multiple reasons, including a negative perception of nursing homes, unsupportive working conditions, and poor pay and benefits.
|
From page 222... ...
THE OVERALL NURSING HOME WORKFORCE The number and types of staff members in a nursing home vary depending on the number of residents, the complexity of their needs, and the scope of services provided. While nursing homes employ many workers directly, they may also provide care through referrals to consultants or by contracting workers rather than hiring them as employees.
|
From page 223... ...
also play an important role in the care of nursing home residents. Family caregivers, described as "an invisible workforce in nursing homes," are an essential component of the workforce, providing care even
|
From page 224... ...
supervisors Community and Social Service Social workers, social and human service assistants, (2 percent) substance abuse and mental health counselors, community health workers, and clergy Production Occupations Laundry workers (1 percent)
|
From page 225... ...
(See later in this chapter for more on family caregivers and volunteers.) Interdisciplinary Team Care in the Nursing Home Meeting the physical, psychosocial, mental, emotional, and spiritual needs of persons in nursing homes requires an interdisciplinary approach.
|
From page 226... ...
NURSING HOME ADMINISTRATION AND LEADERSHIP A variety of personnel provide high-level leadership in nursing homes. The national median for turnover of "top level executives" at nursing 2 The Resident Assessment Instrument collects data to guide care planning and monitoring for long-term care residents.
|
From page 227... ...
Aside from having an appropriate level of staffing, nursing homes require properly prepared highly skilled leadership teams that can balance the financial, operational, and clinical aspects of this incredibly complex business. Administrator A nursing home administrator has oversight and operational responsibilities, including ensuring regulatory compliance, supporting the rights of residents, and maintaining financial accountability.
|
From page 228... ...
. High turnover among the top management at nursing homes has been associated with a higher turnover of nursing assistants and licensed nursing staff (Castle, 2005)
|
From page 229... ...
. In fact, the 2020 CMS Coronavirus Commission on Safety and Quality in Nursing Homes report reinforced "the importance of medical director engagement in nursing home emergency management planning and execution" (MITRE, 2020, p.
|
From page 230... ...
. In his testimony to this committee, Michael Wasserman, California Association of Long Term Care Medicine, noted: There are far too many medical directors who lack even basic knowledge of geriatric medicine concepts and who have little expertise or even inter est in the complex regulatory framework of nursing homes.
|
From page 231... ...
. A survey of directors of nursing in Florida nursing homes found that two-thirds or more held additional roles such as infection prevention and control (68 percent)
|
From page 232... ...
, no federal or state requirements specify minimum education requirements, continuing education requirements, or additional training requirements for directors of nursing. Previous IOM reports on nursing home quality pointed to the lack of educational preparation for directors of nursing to serve as the top-level nurse leader and administrator of the organization in the context of the complexity of the environment and role (IOM, 1996, 2001b)
|
From page 233... ...
Larger not-for-profit nursing homes and nursing homes that are not part of a chain are the most likely to hire a degreed and licensed social worker as a social services director. In 2020, the median salary for a director 4 For more information on the certification exam, see https://www.nadona.org/product/cert director-of-nursing-cdon (accessed November 3, 2021)
|
From page 234... ...
Federal nursing home regulations require an initial visit by a physician within the first 30 days of a nursing home resident's admission, although other required visits may alternate between a physician and other qualified practitioners.5 For initial visits at nursing homes that are not specifically designated as skilled nursing facilities, clinicians not employed by the facility may do the initial visit and documentation.6 Primary care providers are also responsible for writing and signing progress notes for each medical care visit and signing and dating all medical orders. The American Medical Directors Association outlines the comprehensive role of the attending primary care provider in the nursing home (AMDA, 2003)
|
From page 235... ...
. While the numbers of SNFists are growing, particularly among APRNs, there is extreme variation; many nursing homes have almost no full-time primary care providers while in others, almost all residents have a full-time provider (Goodwin et al., 2021)
|
From page 236... ...
. Advanced Practice Registered Nurses The APRN role in providing care in nursing homes emerged in the early 1980s and grew in popularity after the 1986 IOM report Improving the Quality of Care in Nursing Homes (IOM, 1986)
|
From page 237... ...
LICENSED NURSES Two types of licensed nurses work in nursing homes: licensed practical/vocational nurses (LPNs/LVNs)
|
From page 238... ...
Federal regulations require that an RN conducts or coordinates required assessments using the Resident Assessment Instrument with the appropriate participation of other health professionals.7 Additional roles that RNs may have in nursing homes include quality improvement, infection prevention and control, staff development, management, and supervision. LPN/LVNs may fulfill those roles in some nursing homes.
|
From page 239... ...
. The CMS Coronavirus Commission on Safety and Quality in Nursing Homes also called for training of RNs, LPNs, and CNAs in long-term care settings (MITRE, 2020)
|
From page 240... ...
of meeting these standards, and other challenges. Quality of Care Decades of evidence support the association between inadequate nurse staffing and poor quality of care in nursing homes, particularly in the case of RNs (Aiken, 1981; Eagle, 1968; Harrington et al., 2021; IOM, 1996; Spilsbury et al., 2011; Wells, 2004)
|
From page 241... ...
. In addition to the numbers of staff in nursing homes being insufficient to meet the needs of residents, the CMS report identified several other staffing-related issues that contributed to poor quality in nursing homes, including high staff turnover and low retention, inadequate expenditures on nurse staffing, needs related to staff training/competencies, and ineffective or inadequate management and supervision (Feuerberg, 2001)
|
From page 242... ...
. Instead, current regulations include a vague nurse staffing requirement that nursing homes must provide "sufficient nursing staff to attain or maintain the highest practicable .
|
From page 243... ...
of direct care nursing staff time are needed just to prevent poor outcomes, state staffing requirements, with a few exceptions, are nowhere near that recommended level" (Consumer Voice, 2021, p.
|
From page 244... ...
Data collected by CMS are helpful to the state survey process. For example, CMS shares weekend staffing data with state survey agencies so that they may target weekend inspections to nursing homes that report lower weekend staffing levels (OIG, 2021)
|
From page 245... ...
INFECTION PREVENTION AND CONTROL LEADERSHIP In 2016, CMS issued a final rule revising the requirements that nursing homes (and other long-term care facilities) must meet to participate in Medicare and Medicaid programs.
|
From page 246... ...
. The commission made several recommendations related to the role of the infection preventionist, including • Employ infection preventionists with educator capabilities and document their training of the nursing homes staff; • Assess infection prevention and control competency among all nursing home staff; 11 CMS Requirements for Long-Term Care Facilities -- Infection Control, 42 CFR § 483.80 (2016)
|
From page 247... ...
Social Workers Social workers' roles in nursing homes support person-centered care and include identifying and assessing residents' psychosocial needs; working as part of the interdisciplinary care team; communicating and assisting residents and their families with care needs (e.g., behavioral health and psychosocial care) (see Chapter 4)
|
From page 248... ...
. Regulatory Requirements Currently, federal regulations13 require nursing homes with 120 or more beds to hire a qualified social worker on a full-time basis, although this "qualified social worker" need not have a social work degree (BernKlug et al., 2021a)
|
From page 249... ...
concluded that the 120-bed rule "does not account for the level of psychosocial need among residents in smaller nursing homes, nor does it consider the caseload of practitioners." Many individual states have their own regulations regarding social work services in nursing homes, and while most do not require nursing homes with 120 or fewer beds to employ social workers, Connecticut, Maine, and Oklahoma do require that nursing home residents have access to social work services regardless of the size of the nursing home. However, 10 states do not require a "qualified social worker" to have either a social work license or a social work degree, though some require either completing a state-approved course or having some direct supervision and minimum years of experience (Bern-Klug, 2008; Bern-Klug et al., 2018)
|
From page 250... ...
In spite of these recommendations, the final rule did not require social workers as core members of the team developing a resident's comprehensive care plan. Furthermore, the rule added an undergraduate degree in gerontology as an acceptable degree for a "qualified social worker." The reduction in standards for qualified social workers in nursing homes occurred at the same time that these updated regulations increased requirements for psychosocial care, person-centered care, and behavioral health care (CMS, 2016)
|
From page 251... ...
. Furthermore, a study on social integration and mental and functional health outcomes for nursing home residents found that nursing homes with degreed social workers have the capacity to provide better psychosocial care (Leedahl et al., 2015)
|
From page 252... ...
However, evidence on these individuals specifically in nursing homes is extremely limited. Dental Health Care Workforce As Chapter 4 describes, "oral disease impacts physical, psychological, and social well-being through pain, diminished function, and reduced quality of life" (Dunbar, 2019; Sifuentes and Lapane, 2020)
|
From page 253... ...
. Federal regulation only mandates that CMS-certified facilities must have a 17 CMS Requirements for Long-Term Care Facilities -- Pharmacy Services, 42 CFR § 483.45 (2022)
|
From page 254... ...
Nursing homes are required to provide or consult for specialized rehabilitative services for a mental disorder and intellectual disability (e.g., physical therapy, speech–language pathology, occupational therapy, respiratory therapy) for nursing home residents as required by their care plans.19 Occupational Therapists and Assistants In nursing homes, occupational therapists "address training in self-care skills; training in the use of adaptive equipment, compensatory techniques, 18 CMS Requirements for Long-Term Care Facilities -- Food and Nutrition Services, 42 CFR § 483.60 (2016)
|
From page 255... ...
Specifically, staffing levels in nursing homes fell by about 6 percent for physical therapists and 10 percent for physical therapy assistants (McGarry et al., 2021a)
|
From page 256... ...
CNAs -- nursing assistants who have met specific federal and state educational and training requirements -- make up the largest proportion of direct-care workers in nursing homes. Demographics More than 527,000 nursing assistants were employed or contracted by nursing homes across the United States in 2020 (12 percent of the total direct-care workforce)
|
From page 257... ...
. Wages The mean hourly wage in 2020 for nursing assistants in nursing homes was $15.41, and the mean annual wage was $32,050 (BLS, 2021c)
|
From page 258... ...
"Staff are incredibly caring people who need to be paid a living wage." -- Family Member, Berkeley, California "If they paid workers more, maybe there would be more and better care and at the prices being charged per month, I don't see why they can't." -- Wendy "I wonder if the pay should be higher for people in the trenches and not corporate level." -- Family Member, Sioux Falls, South Dakota These quotes were collected from the committee's online call for resident, family, and nursing home staff perspectives.
|
From page 259... ...
. For example, one small study found that CNAs in nursing homes had inadequate knowledge related to aging, cognition, and mental health (Kusmaul, 2016)
|
From page 260... ...
21 CMS Requirements for Long-Term Care Facilities -- Training Requirements, 42 CFR § 483.95(g)
|
From page 261... ...
had a median hourly wage of $15.66 in nursing homes (HHCS, 2020)
|
From page 262... ...
. Contributors to these high turnover rates among direct-care workers in nursing homes include characteristics related to the nature of the job itself and the working environment found in nursing homes, including factors that result in injury.
|
From page 263... ...
. • Create formal promotion programs, peer mentoring programs, and tuition reimbursement programs and proactively engage nursing assistants in efforts to enact such programs (Kemper et al., 2008; Stone and Dawson, 2008)
|
From page 264... ...
. Green House nursing homes employ modified staff roles to split work, empower staff, and have staff members work together.
|
From page 265... ...
However, it's not perfect by any means. I want to have more nurses making high-impact decisions; want more scrutiny into training requirements of administrators; want advanced practice nurses to lead nursing teams; nursing homes to initiate and lead evidence-based projects to improve quality of life and quality of care instead of having to rely on quality improvement organizations." -- Nursing Home Worker, Los Angeles, California These quotes were collected from the committee's online call for resident, family, and nursing home staff perspectives.
|
From page 266... ...
. Family caregivers may be especially important for the continuity of care for nursing home residents with dementia, with responsibilities such as ensuring that the resident is being treated with respect and receiving
|
From page 267... ...
. Family caregivers can also experience high levels of stress and can benefit from improved education and support for themselves.
|
From page 268... ...
. For example, during the COVID-19 pandemic, the Yale School of Medicine Geriatrics Student Interest Group initiated the Telephone Outreach in the COVID-19 Outbreak Program in which student volunteers connected with older adults in nursing homes via weekly phone calls (van Dyck et al., 2020)
|
From page 269... ...
This quote was collected from the committee's online call for resident, family, and nursing home staff perspectives.
|
From page 270... ...
found that racial and ethnic minorities and immigrant direct-care workers -- over 90 percent of whom 80 70 60 50 40 30 20 10 0 Nursing Home Population Nursing Home Workforce CNAs in Nursing Homes White Black/African American Hispanic/Latinx Other FIGURE 5-3 Racial and ethnic diversity (percentage) among nursing home residents, nursing home staff, and CNAs in nursing homes.
|
From page 271... ...
Therefore, all workers in nursing homes, including leadership, will likely benefit from training in principles of diversity, equity, and inclusion. Providing Culturally Sensitive Care In addition to concerns for the power dynamics and hierarchies of the workforce itself, the contrast between the diversity of the nursing home workforce and the residents they serve (see Figure 5-3)
|
From page 272... ...
A 2012 study comparing staffing levels and deficiencies of for-profit nursing homes and five other ownership groups found that the 10 largest for-profit nursing home chains had lower RN and total nurse staffing hours than government facilities when controlling for other factors, and that they received 36 percent higher deficiencies (and 41 percent higher serious deficiencies) than government facilities (Harrington et al., 2012)
|
From page 273... ...
For a family member perspective on consistent assignment, see Box 5-11. COVID-19 AND NURSING HOME STAFFING The COVID-19 pandemic resulted in disproportionate deaths of residents in nursing homes.
|
From page 274... ...
One study found that while nursing homes with higher staffing ratios (just prior to the pandemic) did not have a reduced probability of an initial outbreak, higher baseline staffing ratios were helpful in stemming an outbreak once it started (Figueroa et al., 2020)
|
From page 275... ...
. In December 2021, on average, 30.1 percent of nursing homes had shortages of nurses or nurse aides (AARP, 2022)
|
From page 276... ...
McGarry and colleagues (2020) found that early in the pandemic, about one in five nursing homes had shortages of PPE, particularly gowns and N95 respirators.
|
From page 277... ...
. The program also went beyond immediate technical assistance and provided weekly educational webinars, assisted with procurement of resources, and provided payment incentives to nursing homes (Lipsitz et al., 2020)
|
From page 278... ...
. KEY FINDINGS AND CONCLUSIONS The Overall Nursing Home Workforce • A wide variety of workers help to support nursing home residents in achieving their goals and preferences.
|
From page 279... ...
• The most frequently mentioned barrier for increasing the role of APRNs in nursing homes is their restricted scope of practice due to Medicare regulations and state regulatory constraints. Nurse Staffing • Nursing staff (including RNs, LPN/LVNs, and CNAs)
|
From page 280... ...
• Nursing homes employ too few chaplains to meet the needs of seri ously ill patients and may instead designate social workers to get additional education or find a volunteer chaplain. Certified Nursing Assistants (CNAs)
|
From page 281... ...
. Advancing Excellence (Advancing Excellence in America's Nursing Homes)
|
From page 282... ...
2014. Nurse staffing impact on quality of care in nursing homes: A systematic review of longitudinal studies.
|
From page 283... ...
2012. Medicare wants only ‘independent' consultant pharmacists in nursing homes.
|
From page 284... ...
2015. Resident-to-resident aggression in nursing homes: Social worker involve ment and collaboration with nursing colleagues.
|
From page 285... ...
2009. Effectiveness of nurse practitioners in nursing homes: A systematic review.
|
From page 286... ...
2021. Informal caregivers provide considerable front-line support in residential care facilities and nursing homes.
|
From page 287... ...
2006. Interdisciplinary care planning and the written care plan in nursing homes: A critical review.
|
From page 288... ...
2001. Report to Congress: Appropriateness of minimum nurse staffing ratios in nursing homes: Phase II final report.
|
From page 289... ...
nursing homes. Journal of the American Geriatrics Society 68(11)
|
From page 290... ...
2011. The influence of nurse staffing levels on quality of care in nursing homes.
|
From page 291... ...
2021. A call to the CMS: Mandate adequate professional nurse staffing in nursing homes.
|
From page 292... ...
2021. Structural charac teristics of nursing homes and social service directors that influence their engagement in disaster preparedness processes.
|
From page 293... ...
2019. The relationship between quality of care, physical therapy, and occupational therapy staffing levels in nursing homes in 4 years' follow-up.
|
From page 294... ...
2020. Coronavirus Commission for Safety and Quality in Nursing Homes: Commission final report.
|
From page 295... ...
2018. Interchangeability of licensed nurses in nursing homes: Perspectives of directors of nurs ing.
|
From page 296... ...
2013. The influence of teams to sustain quality improvement in nursing homes that "need improvement." Journal of the American Medical Directors Association 14(1)
|
From page 297... ...
Structural and contextual de terminants of social service staffing in nursing homes. Health & Social Work 42(1)
|
From page 298... ...
2022. Association between wages and nursing staff turnover in Iowa nursing homes.
|
From page 299... ...
2012. Envisioning quality psychosocial care in nursing homes: The role of social work.
|
From page 300... ...
2021. Federal requirements for nursing homes to include certified nursing assistants in resident care planning and interdisciplinary teams: A policy analysis.
|
From page 301... ...
nursing homes, 2001–2010. Journal of the American Medical Directors Association 14(11)
|
From page 302... ...
nursing homes. Journal of the American Medical Directors Association 22(5)
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.