Nursing Staff in Hospitals and Nursing Homes Is It Adequate? (1996) / Chapter Skim
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Nursing Staff and Quality of Care in Nursing Homes
Nursing Staff and Quality of Care in Nursing Homes
Pages 361-425
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From page 361... ...
The next two sections discuss the future demand for nursing home care and some selected issues in long-term care. The fifth section presents a detailed review of research relevant to the linkage of staffing and quality of care.
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From page 362... ...
With passage of the Kerr-Mills Medical Assistance to the Aged Act in 1950, which allowed for direct payment to care providers, and with increases in the number of older adults in the population, the nursing home industry boomed. In 1954, the American Nursing Home Association lobbied for and won the right for nonprofit nursing homes to be built in conjunction with hospitals using Hill-Burton funds.
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From page 363... ...
By and large, health planners and economists failed to recognize the additional staffing and financial burdens these mentally ill and cognitively impaired residents placed on the nursing home system (Vladick and Alfano, 1987~. The current trend, however, is for integrated interdisciplinary treatment teams to provide psychiatric care in nursing homes, an approach that allows for the use of psychopharmacologic, psychoeducational, behavioral, and family or social interventions.
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From page 364... ...
traditional nursing homes, which primarily are facilities that provide either intermediate-level nursing care or skilled nursing care, but might also include "board-and-care" residential homes, and (2) recent alternatives to the traditional nursing homes, such as foster care homes, family homes, or assistedliving homes.
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From page 365... ...
, found wide geographic variations in the prevalence of nursing homes versus board and care homes or home care (Brown University Long-Term Care Quality Letter, 1994~. The Midwest relied heavily on regular nursing homes, little on board and care, and moderately on home care.
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From page 366... ...
, case-mix refers to distinctions of residents related to resource use where resource use is primarily defined as a ratio of nursing time to costs. Nursing home residents are a heterogeneous mix of vulnerable adults whose ages may span more than 50 years.
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From page 367... ...
Thus, with OBRA 87 setting the standard for quality of care in long-termcare facilities, the nursing home industry today is among the most highly regulated businesses in America. Beset with regulations developed in response to perceived abuses and poor quality care, licensed nursing homes are charged with providing care that meets the vast needs of diverse residents, yet often they must try to meet that charge with only minimum reimbursement and inadequate staffing (Hall, 1995~.
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From page 368... ...
Public expenditures for community-based services are relatively small compared to those for nursing home care (O'Shaunessy and Price, 19871. Medicaid, which is the principal source of funding of health care services for low income persons, finances mostly nursing home care and was not designed to support a full array of social and other long-term-care community-based services.
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From page 369... ...
Nursing assistants are the primary care givers in long-term care. Consequently, the care that they provide is an important determinant of the quality of life and quality of care for nursing home residents.
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From page 370... ...
In their report to the chairman, the committee listed several reasons for a lack of health care personnel trained in geriatrics and gerontology: difficulty recruiting and retaining qualified personnel for direct care in nursing homes, poorly trained workers, little training of family and friend care givers, vague job descriptions, shortages of qualified faculty to teach the needed knowledge and skills to physicians, nurses, and other health professionals, and the lack of appropriate training sites. Clearly, low salaries for nursing home personnel contribute to recruitment and retention problems and low reimbursement rates affect nursing home providers' interest in paying higher salaries.
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From page 371... ...
The median hourly wage reported by hospital aides was $7.12 between 1987 and 1989, compared to $5.29 for nursing home aides and $4.22 for home care aides. Noting that RNs are a critical component of the rural health care delivery system and in some areas the sole providers of care, the Select Committee on Aging (1992)
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From page 372... ...
At the same time, the background and characteristics of many nursing home staff may adversely affect their job performance (Burgio and Scilley, 1994~. The lives of many nursing assistants, in particular, are beset with personal problems and tragedies that leave them with too few personal resources to respond effectively to residents and that interfere with their ability to provide quality care to the frail, dependent elderly (Tellis-Nayak and Tellis-Nayak, 1989~.
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From page 373... ...
Preliminary findings from a study of ethnic and racial conflict between nursing home staff and residents in New York revealed a high prevalence of racially charged verbal abuse and name calling of aides by residents (Teresi et al., 1994~. Institutional Care Needs of Minority Elderly There is a lack of research and thus an inadequate knowledge base about the long-term health care needs of minority elders and other age groups.
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From page 374... ...
found strong evidence that Mexican American nursing home residents are more cognitively and functionally impaired, after controlling for age and education, than non-Hispanic white residents. They also were significantly more likely to be funded by Medicaid, and they were more likely to have lived with relatives prior to institutionalization.
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From page 375... ...
Abuse also occurs, however, in institutional settings. Research conducted in one 200-bed nonprofit nursing home suggests that the majority of nursing assistants are kind and helpful most of the time, although abuse (primarily psychological abuse such as yelling, swearing, and being insulting)
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From page 376... ...
found 9 percent of nursing home and 34 percent of intermediate care residents had no aggressive behaviors, while 84 percent of nursing home residents and 57 percent of intermediate care residents had behaviors that endangered themselves or others. A study by Everitt and coworkers (1991J documented that the three most distressing resident behaviors nursing staff encountered were physical abuse, verbal abuse, and wandering.
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From page 377... ...
Yet the number of available nursing home beds whether in traditional nursing homes or alternatives such as in-home care- is less per capita in these areas than in urban areas, and the shortage of RNs is greater in rural areas and in areas where the more impoverished elderly reside (Select Committee on Aging, 1992~. Although Medicaid pays at least some of the costs of care for about 60 percent of nursing home patients, efforts by states to control costs of Medicaid have tended to limit the supply of nursing home beds.
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From page 378... ...
is also expected to increase to somewhere around 50 percent. Recent estimates indicate that one-half of the women and almost one-third of the men who turned 65 in 1990 will require nursing home care during their life.
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From page 379... ...
More than 50 percent of nursing home admissions currently come from hospitals, with most needing care for unstable medical conditions. According to a report on a subacute care demonstration project in Illinois (McKnight's Long-term Care News, 1993)
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From page 380... ...
The total number of medications for each patient was not significantly different for SCU versus traditional unit patients, and the number per patient did not increase over the 1-year study period. A multicenter collaborative initiative, funded by the National Institute on Aging and designed to explore the effectiveness of SCUs, evaluate specific interventions and family involvement in care, and compare SCU outcomes to those of traditional nursing home care, is currently under way.
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From page 381... ...
In our view, the OBRA regulations are minimal and do not go far enough in requiring 24-hour RN coverage with specific numbers of assisting staff for a specific number of residents to assure quality of care and reasonable work expectations for staff. The American Nurses Association has advocated for quality nursing home care by promoting RN coverage around the clock, nurse aide training and certification, and opposing waivers of OBRA licensed nurse requirements.
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From page 382... ...
Finally, we review research that examines the relationship between quality of care and environmental factors such as reimbursement policies, type of facilities, and management systems or organizational climate. Definitions and Measurement of Quality Few concepts have been more elusive, controversial, or politically volatile than nursing home quality of care.
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From page 383... ...
Whether or not adequate resources are available to provide quality care is still an issue, and many would agree that resources are often not adequate. For example, the study conducted by the Institute of Medicine's Committee on Nursing Home Regulation supported higher nursing staff standards as a major means for assuring quality of care in nursing homes, along with new staffing, training, and registry requirements for nursing staff (IOM, 1986~.
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From page 384... ...
Although families continue to be involved in care following placement of their loved one in a nursing facility, relatively little is known about the relationships among families and nursing home staff, especially from the perspective of family members (Duncan and Morgan, 1994~. What research has been conducted in this area indicates that families equate good quality nursing home care with care that is affectively appropriate, emotionally sensitive, respectful, and professional, and that emphasizes a personal relationship with the resident.
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From page 385... ...
Few would argue that this is adequate to implement all that OBRA requires for assuring quality of care for nursing home residents, let alone to move beyond minimum standards. Without increased reimbursement, the nursing home industry will likely continue to seek ways to compromise OBRA standards, especially regarding RN staffing.
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From page 386... ...
has been conducted in the area of staff turnover, and the important other side of the coin, staff retention (Robertson et al., 19943. Turnover in nursing staff is generally affected by a variety of factors leading to low job satisfaction, including low compensation and benefits, poor working conditions and quality of the nursing home, few opportunities for advancement, and problems with staff relationships (Birkenstock, 1991~.
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From page 387... ...
Thus, to promote staff retention in long-term care and to make nursing homes a more attractive and satisfying practice setting, administrators must recognize both the importance to nurses of patient care factors and the authority to manage patient care issues and make clinical decisions, and the need to provide RNs with attractive compensation and benefits, recognition, training, and participation in decision making about their work. Stress and Burnout Nurses who work with the elderly confront many complex and potentially stressful care situations.
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From page 388... ...
Burnout, a phenomenon characterized by loss of concern for residents, and physical, emotional and spiritual exhaustion, may lead to indifference or negative feelings toward elderly residents, overuse of chemical or physical restraints, and heightened potential for abuse (Heine, 1986~. Burnout has also been shown to result in administrative difficulties such as high rates of tardiness, absenteeism, and attrition (Goldin, 1985~.
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From page 389... ...
Moreover, nursing home staff are often poorly trained to cope with the disruptive behaviors of residents, and they are therefore repeatedly frustrated by their inability to manage recurrent problems (Stolley et al., 1991~. Many nursing homes are also not equipped with environmental structures or the support and service systems required to care appropriately for the person with Alzheimer's disease (Peppard, 1984~.
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From page 390... ...
suggests that physical and architectural features, such as adequate space, separate activity rooms, staff offices and toilet facilities, resident care facilities, barrier-free hallways, visible exits with amenities such as wide entry doors and ramps, and emergency exits, may decrease caregiver burden and stress. Enhancing social support networks is another important strategy that can serve as a buffer against the stresses inherent in working with the elderly.
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From page 391... ...
argued that dedicated and compassionate nursing staff are essential for maintaining high quality care on a day-to-day basis. Further, few would disagree that nurse aides need to be skilled in providing care, given that they make up about 85 percent of nursing home personnel and provide the majority of direct care.
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From page 392... ...
The lack of skilled care givers and adequate resources to meet the mental, emotional, and behavioral problems of nursing home residents suggests that without specialized psychiatric interventions the mental health needs of the elderly residing in nursing homes will remain unmet or be treated inappropriately (Stevens and Baldwin, 19881. Consultations with skilled mental health professionals is thus an important and effective intervention (Parsons et al., 1988; Smith et al., 19941.
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From page 393... ...
Thus, while nursing staff in nursing homes should have higher salaries and more help, just giving them more money and adding more staff is not the total answer. More specific protocol and management technologies also are needed in order to actually achieve higher quality care.
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From page 394... ...
indicated that insufficient and inadequately trained nursing staff was a contributing factor to the deterioration and eventual hospitalization of nursing home residents. Other research supports the notion that staffing is an important variable that influences eating behavior (Kayser-Jones, 19941.
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From page 395... ...
Otherwise, supervisory staff can only carry out inspections to ensure that the worst practices are avoided. Some experts believe that nursing homes that rely on predominately unskilled nursing staff jeopardize the quality of nursing home care (Shields and Kick, 19823.
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From page 396... ...
In an observational study of staff behaviors in a nursing home, Burgio and colleagues (1990) found that LPNs displayed significantly more patient care behaviors and nurse aides significantly more nonwork behaviors than other nursing staff.
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From page 397... ...
Heine, personal communication, 1995~. Studies of advanced practice nurses, such as clinical nurse specialists and geriatric nurse practitioners, 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 398... ...
supports the assertion that RN leadership is a key to achieving quality outcomes in nursing homes. Other research that tests interventions in nursing homes also supports the need for a continuous professional nurse presence to provide leadership and direction for assisting staff (Evans and Strumpf, 1989J.
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From page 399... ...
The behavior and attitudes of NAs can play a critical role in the quality of life of nursing home residents, and yet high attrition rates and alienation have been reported by nursing assistants.
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From page 400... ...
found that the physical care of nursing home residents in the United States deteriorated during periods of high staff turnover, while Stryker (1981) hypothesized that depression, disengagement, disorientation, and isolation among long-term-care residents is likely to increase when staff-resident relationships are disrupted by high turnover.
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From page 401... ...
A study of 285 nursing home residents found that their behavioral problems influenced the care they received. Lack of cognitive ability caused staff to spend more
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From page 402... ...
These data, together with other supporting literature, indicate that mental health problems clearly affect the amount of nursing time that elderly long-term-care residents require. This suggests that nursing homes must be reimbursed in a way that permits and encourages mentally ill and cognitively impaired residents to receive needed psychosocial services.
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From page 403... ...
Quality, Management Systems, and Organizational Climate Management Systems Management procedures are noted to play a critical role in the maintenance of staff performance (Sheridan et al., 1992~. Direction, delegation, assertiveness, recognition, reprimand, liaison, and sensitivity are leadership dimensions that have been found to have significant effects on the job attitudes and job performance of nursing staff in nursing homes and hospitals (Sheridan et al., 1984; Sheridan et al., 1990~.
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From page 404... ...
312) suggests that those nursing homes that successfully break the hopeless cycle of high staff attrition, low morale, and indifferent care have managed to "create an institutional structure that remains sensitive to the nurse's aides needs, nurtures their idealism, and values their central role." The relationships between social climate, quality of care, and resident health and well-being are increasingly being recognized.
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From page 405... ...
Formal and continuing education in geriatric and gerontological nursing for all nursing staff is another key to the achievement of quality outcomes for residents. A model of professional nursing practice in a nursing home is demonstrated at the Iowa Veterans Home (IVH)
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From page 406... ...
For example, the number of indwelling catheters and decubiti was much lower after the model of practice was implemented, even though the proportion of residents with complex nursing care problems increased. The rates of monitors of poor quality care also were consistently below the average rates for comparable long-term-care institutions.
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From page 407... ...
Analysis of residents in facilities reimbursed using a case-mix formula indicated that the percentage of light care residents is less under these incentives. · There is still a critical need for research to examine the role that nursing homes should play in long-term care, including what residents are best served by what types of facilities.
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From page 408... ...
The use of consultant RNs, who are hired by some nursing homes to come in specifically to fill out the MDS, adds to concern about the reliability and validity of the data for measuring quality of care. · Investigations to assess the reliability and validity of MDS data and to test other strategies for assuring the reliability and validity of quality care data in nursing homes are needed.
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From page 409... ...
· Clearly, the etiology and appropriate management of aggressive behaviors of nursing home residents against staff, and vice versa, is an area deserving of more research. · Further studies also are needed to better understand the specific causes of elder abuse and to test interventions for institutional staff and families that are designed to prevent instances of abuse.
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From page 410... ...
Based on the current literature and research findings, more research is needed to document: (1) how families and nursing home staff can best work together to achieve quality care outcomes, (2)
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From page 411... ...
Based on the review of the historical background of nursing homes, the current status and future demand for nursing home care, and research relevant to the linkage of staffing and quality care, the following policy recommendations are set forth. Recommendation 1: The minimum standards for the number of RNs in nursing homes should be increased.
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From page 412... ...
presence in nursing homes for the provision of quality care. This paper emphasized the need for RN leadership, direction, and supervision of assisting nursing staff because: (1)
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From page 413... ...
Recommendation 10: Require nursing homes to provide a minimum of three hours of didactic and three hours of supervised practicum education annually for staff and family members on techniques for managing and preventing disruptive and aggressive resident behaviors. Recommendation 11: Require nursing homes to educate families and staff, both at the time of resident admission and with periodic reinforcement, about how to interact with each other to be mutually supportive and to recognize quality care outcomes.
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From page 414... ...
merging the categories of geriatric nurse clinical specialists and geriatric nurse practitioners, and preparing geriatric nurses in advanced practice roles to provide primary and comprehensive care to the elderly in nursing homes; (4) developing model geriatric nursing curricula that incorporate advanced information technologies at both undergraduate and graduate levels; (5)
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From page 415... ...
Adequate compensation for nurses who work with the elderly needs to be assured to provide incentives for increased recruitment and retention of qualified nurses in nursing homes. Advanced information technologies (i.e., fiber optic and digital networks)
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From page 416... ...
Presentation at special session on staffing and quality care in nursing homes, at the annual meeting of The Gerontological Society of America, Atlanta, Georgia, November 1994. Baltz, T.M., and Turner, J.G.
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From page 417... ...
Burgio, L.D. Presentation at special session on staffing and quality care in nursing homes, at the annual meeting of The Gerontological Society of America, Atlanta, Georgia, November 1994.
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From page 418... ...
Presentation at special panel session on staffing and quality of care in nursing homes, at the annual meeting of The Gerontological Society of America, Atlanta, Geor3ia, November 1994. Fries, B.E., and Cooney, L.M.
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From page 419... ...
Jones, D.C., Bonito, A., Gower, J., and Williams, R Analysis of the Environment for Recruitment and Retention of Registered Nurses in Nursing Homes.
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From page 420... ...
Linn, M, Gurel, L., and Linn, B.A. Patient Outcome as a Measure of Quality of Nursing Home Care.
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From page 421... ...
Mezey, M.D. Presentation at special session on staffing and quality of care in nursing homes, at the annual meeting of The Gerontological Society of America, Atlanta, Georgia, November 1994.
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From page 422... ...
The Influence of Registered Nurse Staffing on the Quality of Nursing Home Care. Research in Nursing and Health 13:263-270, 1990.
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From page 423... ...
Aggressive Behavior in Cognitively Impaired Nursing Home Residents. Research In Nursing and Health 14(2)
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From page 424... ...
Presentation at special session on staffing and quality of care in nursing homes, at the annual meeting of The Gerontological Society of America, Atlanta, Georgia, November 1994. Strumpf, N.E., and Knibbe, K.K.
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From page 425... ...
Zinn, J.S. The Influence of Nurse Wage Differentials on Nursing Home Staffing and Resident Care Decisions.
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