Nursing Staff in Hospitals and Nursing Homes Is It Adequate? (1996) / Chapter Skim
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6 Staffing and Quality of Care in Nursing Homes
6 Staffing and Quality of Care in Nursing Homes
Pages 128-168
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From page 128... ...
The previous chapter explores the relationship of staffing patterns of nursing personnel to quality of patient care in hospitals and examines the structural variables of staffing and their relationship to processes and outcomes of care. This chapter examines the interrelationship of quality of care and staffing in nursing homes.
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From page 129... ...
Defining quality in nursing facilities has been a difficult process. Quality of care in nursing homes has been defined both as an input measure and as an outcome (Kruzich et al., 1992~.
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From page 131... ...
Thus, these rights also constitute elements of quality captured by the process measures. The outcomes of nursing home care include changes in health status and conditions attributable to the care provided or not provided.
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From page 132... ...
It singled out problems of residents being treated with disrespect and of frequently being denied any choices of food, roommates, the time they rise and go to sleep, their activities, the clothes they wear, and when and where they may visit with family and friends. The committee stated flatly that the quality of medical and nursing care in nursing homes "left much to be desired" (p.
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From page 133... ...
Problems with the regulatory process had been identified in an evaluation of state survey processes (Zimmerman et al., 1985~. Because of the growing concern about nursing home quality, Congress requested a study by the IOM to examine the regulation of nursing facilities.
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From page 134... ...
Second, the 1990 regulations mandated comprehensive assessments of all nursing home residents, using the MDS forms (Morris et al., 19901. Nursing facilities are required to complete the MDS forms for each resident within 14 days of admission, when there are major changes in health status, and at least annually.
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From page 135... ...
This system designed the nursing home minimum data set mentioned above for resident assessment and developed detailed protocols for resident assessment of specific problem areas to guide the care planning process (Morris et al., 1990~. The purpose is to assess the functional, cognitive, and affective levels of residents.
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From page 136... ...
Consumer groups, staff, and providers report some improvements in nursing home care (Cotton, 1993; Fagin et al., 1995; 1995 IOM public hearings)
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From page 137... ...
Improper restraints (Residents have the right to be free of physical restraints used for discipline or facility convenience) No comprehensive assessment (The facility must make a comprehensive assessment of resident needs)
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From page 138... ...
found that a number of facilities fail to recognize and promote the independence of residents. They found that despite the implementation of OBRA 87 regulations, nearly one-third of North Carolina nursing home residents remained physically restrained.
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From page 139... ...
A recent study by Phillips and colleagues (1993) found that physical restraints continue to be overused but that the use of such restraints actually requires more, rather than less, staff time and care and therefore may increase total nursing home costs.
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From page 140... ...
In summary, despite the recent improvements in nursing home quality and regulatory compliance, in the committee's judgment the quality of care provided by some nursing facilities still leaves much to be desired. The number and type of deficiencies and complaints reported by state licensing agencies, consumer advocacy groups, families, and residents show poor quality in some facilities.
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From page 141... ...
Status of Staffing The committee sought to determine if staffing as a measure of quality of care in nursing homes has improved as a result of OBRA 87, subsequent federal legislation, and the responses of state governments. In attempting to answer that question, the committee examined three types of evidence: government standards, empirical evidence, and committee testimony and site visits.
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From page 142... ...
With the adequacy of the RN supply at the present time and reported layoffs in hospitals, nursing facilities should have less difficulty in meeting this statutory requirement without waivers. The committee strongly endorses the intent of OBRA 87 and supports efforts made by facilities and states to improve professional nurse staffing in nursing homes consistent with the intent of the statute.
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From page 143... ...
mined that overall staffing ratios for RN time and total staff time per resident day had increased very slightly over the 18 minutes of RN time and 2 hours of total staff time per resident day reported in 1985 (NClIS, 1988~. Moreover, most estimates assume that staff are evenly distributed over 24 hours, which is generally not the situation.
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From page 144... ...
Many complaints were voiced at the public hearings by resident advocates, licensed nurses, and nurse assistants about inadequate quality of care and staffing shortages at all levels. Representatives of the nursing home industry, however, described improvements in the quality of nursing care indicating that, in their view, staffing was on average adequate.
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From page 145... ...
Current, comprehensive data are needed for research, policy formulation, management of the nursing home industry, and consumer .
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From page 146... ...
Some nursing facilities hire consultant nurses for the purpose of completing the MDS and other documentation (Schnelle, 1994~.4 The committee believes that use of consultant nurses for this purpose only is undesirable, and it strongly discourages facilities from continuing the practice. The committee strongly endorses the concept of an individualized care plan for each resident.
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From page 147... ...
Nursing Staff Levels and Skill Mix Staffing and Resident Characteristics There is universal agreement in the research literature on the strong relationship among resident characteristics, nursing staff time requirements, and nursing costs in nursing facilities. Several studies have examined these relationships and attempted to quantify them (Weissert et al., 1983; Arling et al., 19871.
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From page 148... ...
Nursing care is a major service provided by nursing homes. Some experts believe that nursing facilities that rely predominantly on unskilled nursing staff with minimal presence of licensed nursing staff jeopardize the quality of nursing home care.
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From page 149... ...
Based on analysis of 2,500 nursing home residents in 80 nursing facilities in Rhode Island, Spector and Takada (1991) used multivariate models to estimate what structure and process variables are associated with resident outcomes after controlling for resident characteristics.
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From page 150... ...
Braun (1991) , in a retrospective cohort study of 390 veterans discharged to 11 nursing homes and followed for 6 months investigated the relationship between nursing home quality and patient outcomes of mortality, rehospitalization, and discharge, controlling for severity of illness and case-mix differences.
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From page 151... ...
Gustafson and colleagues (1990) found a significant correlation between nursing staff levels and six measures of quality incorporated into the Quality Assessment Index constructed by them for measuring nursing home quality.
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From page 152... ...
Hence, as the case-mix increases, resident care requires a highly qualified nursing staff present at all times, with the nurse needing a broad base of knowledge covering basic nursing, geriatrics, rehabilitation, and psychiatric skills. Today, an LPN may be the only licensed nurse in a facility in the evenings and night time to attend to resident care; an LPN does not meet the qualification requirements stated above.
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From page 153... ...
They concluded that the current federal requirement of one RN for 8 hours a day, 7 days a week is not sufficient to ensure quality of care for residents. The preponderance of evidence from a number of studies using different types of quality measures has shown a positive relationship between nursing staff levels and quality of nursing home care, indicating a strong need to increase the overall level of nursing staff in nursing homes.
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From page 154... ...
for those hours of LPN time across all nursing facilities in the nation could amount to roughly $338 million. This figure is a rough estimate and may be considered an overestimate since most Medicare-certified facilities and some Medicaid-certified facilities already have RNs on 24-hour duty and because of the expectation, based on the geriatric nurse practitioner studies discussed below, that some offsetting costsavings would be achieved from prevention of complications, higher levels of function, and fewer hospitalization resulting from early detection of signs and symptoms and timely intervention.6 Ultimately, the committee believes that the public's interests and needs for basic quality of care must be considered in addition to cost if we as a society are going to maintain a sense of values and responsibility for the care of the elderly, disabled, and disadvantaged.
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From page 155... ...
and geriatric nurse practitioners (GNP) in nursing homes have shown that they can improve resident outcomes and contribute to quality by changing the focus from custodial to rehabilitative care (Kane et al., 1976, 1988)
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From page 156... ...
Nurse Assistants Nurse assistants constitute 70 to 90 percent of nursing staff in nursing facilities (IOM, 1986b; NCHS, 1987; Maraldo, 1991~. They provide most of the direct care and spend the most time with the residents.
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From page 157... ...
Overall, on the basis of experience and information gathered from the testimonies received, the committee believes that the organization, use, and education of NA staff members make a substantial difference in the humane care, comfort, and health of nursing home residents and in the satisfaction and health of nursing staff. In general, nurse assistants who provide the largest portion of direct personal care to residents receive little training for provision of care in a nursing facility.
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From page 158... ...
RECOMMENDATION 6-4: The committee recommends that research efforts on staffing levels and skill mix specifically address the relationship of licensed practical nurses and nurse assistants to quality of care. Management and Leadership The changing focus of services and the increasingly complex nature of the care provided in nursing facilities place new demands for skills, judgment, supervision, and management of nursing services.
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From page 159... ...
Job Satisfaction, Turnover, and Compensation The committee can find no direct evidence of a relationship between job satisfaction and quality of care, although a relationship is widely perceived to exist (Bond and Bond, 19871. Staff Turnover Nursing homes with higher NA-to-bed ratios and those that include nursing assistants as part of the care team, value their opinions, and acknowledge their important role in provision of quality care have lower turnover rates (Reagan, 1986; Wagnild and Manning, 1986; Willcocks et al., 1987; Wagnild, 1988; Birkenstock, 1991; Robertson et al., 1994; Mor, 19959.
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From page 160... ...
National data on turnover indicate very high rates for all types of nursing personnel in nursing homes, especially nurse assistants (see Table 6.5~. Moreover, staff turnover rates appear to have increased in recent years.
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From page 161... ...
Clearly, the combination of low average wages and benefits contributes to high turnover and poor quality of care. During its site visits and in public testimony the committee heard many comments about the low level of wages and fringe benefits in nursing facilities, with the result that recruiting and retaining nurses are major problems for nursing homes.
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From page 162... ...
EFFECTS OF REIMBURSEMENT AND OTHER FACTORS ON NURSING STAFF Reimbursement and Staffing Method and Level of Reimbursement As discussed in Chapter 3, nursing homes derive most of their revenue from
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From page 163... ...
Presumably because payment is lower and there is excess demand for care on the part of Medicaid eligibles, facilities with high proportions of residents on Medicaid tend to have a lower quality of care as measured by process indicators (Nyman, 1985, 1989b; Gertler, 1989~. Elderly persons who are potentially eligible for Medicaid have experienced access barriers to nursing home care in areas where a high proportion of potential nursing home residents are private (Ettner, 19931.
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From page 164... ...
Case-mix reimbursement generally has not led to increases in nursing staffto-resident ratios. In Maryland, there was no evidence that extra nursing home payments were used to add more staff (Feder and Scanlon, 19891.
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From page 165... ...
With data from the San Diego project, Norton (1992) used the Markov model to represent the resulting health changes of nursing home residents.
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From page 166... ...
The committee found very little research on the role of families in nursing home care. Bowers (1988)
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From page 167... ...
A major barrier to increased staffing in nursing facilities concerns the fiscal limits of governmental support. Since government pays for nearly 63 percent of current nursing home expenditures (Levis et al., 1994)
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From page 168... ...
Since the population of this country is aging and the oldest-old age group is increasing, and there is no cure in sight for chronic diseases such as Alzheimer's, the demand for nursing home care will not abate, even with the growth of alternative long-term care facilities. Funding mechanisms will have to be explored to ensure adequate staffing to care for residents with multiple chronic conditions and with special care or subacute care needs.
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