Nursing Practice in Nursing Homes Sarah Greene Burger, RN-C, MPH, FAAN Ethel Mitty, EdD, RN Mathy Mezey, EdD, RN, FAAN Hartford Institute for Geriatric.

Nursing Practice in Nursing Homes

Sarah Greene Burger, RN-C, MPH, FAANEthel Mitty, EdD, RN

Mathy Mezey, EdD, RN, FAANHartford Institute for Geriatric Nursing, New York University College of Nursing

Module 2 of Nursing Homes as Clinical Placement Sites for Nursing Students Series

© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing

Acknowledgments

This is a joint project of

With support from

Grant to the University of Minnesota School of Nursing


This project is endorsed by:

Project Steering CommitteeView List of Members


About Module 2: Nursing Practice in Nursing

Homes Describe nurse hierarchy, leadership and

governance

Differentiate among nursing staffing: actual and recommended

Analyze the delivery of nursing care in nursing homes

Objectives/Purpose:

At the end of this module you will be able to:

Please note that Module 2 refers to nursing practice in “typical” nursing homes. For information on nurse practice in nursing homes implementing resident directed care and culture change, see Modules 3 and 5.


Analyze Federal staffing requirements as compared to the nursing home's nurse staffing pattern

Analyze the work load of a Certified Nursing Assistant (CNA) during day, evening, and night shifts

Use Criteria to observe the extent to which a resident is receiving rehabilitative and/or restorative nursing

Knowledge of Nurse Staffing

If you know about nurse staffing, you can assign students to:


What the Federal law (Nursing Home Reform Act NHRA, [OBRA ’87] requires for Nurse Staffing as a minimum

RN must be on duty eight consecutive hours/day seven days a weekIn nursing homes with <60 residents, the RN can be the DON and the direct care provider

There are no federal minimum staffing required for CNAs (States can set minimums)

There is no specific nurse-to-resident or CNA-to-resident staffing requirement in federal regulations. Average CNA-to-resident ratio, day shift = 1:8; evening=1:15; night=1:20 (varies with resident acuity/type of unit

Licensed Nurse (RN, LPN/LVN) must be on duty 24/7

Staffing and services must be “sufficient to attain or maintain the highest possible level of physical, mental and psychosocial well-being of each resident.” (NHRA ’87)

Most states exceed federal minimum requirements but do not have sufficient staff to meet level of staffing for optimum care: 4.10 HPRD as recommended by Health and Human Services.* (Zhang NJ et al. (2006). Minimum nurse staffing ratios for nursing homes. Nurse Econ 24(2); 78-85, 93.)


Nurse Staffing in Nursing Homes

There is no research supporting a particular standard/ratio for RN, LPN, CNA staffing in nursing homes

Data show that: Staffing levels below 2.75 HPRD* place residents at risk for harm (1)

RN/LPN .75 HPRD CNAs 2.0 HPRD

Without at least 4.1 HPRD or quality suffers (2) RN/LPN 1.3 HPRD (includes .75 RN care) CNAs 2.8 HPRD

In order to receive a 5-star rating a nursing home must have 4.08 HPRD RN/LPN 1.20 HPRD (includes .55 RN care) CNAs 2.80 HPRD


Nursing Hierarchy in Nursing Homes

• Certified Nurse Assistant (CNA) constitute 70% of nursing staff

One RN on staff: DON. Some DON/DNS have executive title (e.g.,

VP for Resident Care Services).Has “support service” departments reporting to them, e.g. housekeeping, dietary, pharmacy

Supervisor typically has clinical and administrative

responsibilities.

Nurse Manager can also be called “Resident Care Coordinator”

or some variation.

RN Director of Nursing (DON) or Director of Nursing Services (DNS)

RN (or LPN) Supervisoroversees several nursing “units”

An RN (or LPN) Nurse Managerrole of head nurse with 24/7

responsibility and accountability


Knowledge of the Nursing Hierarchy

Observe the communication about a resident's health status among the RN, LPN and CNA

Observe/shadow a nurse manager in order to analyze his/her leadership style

Observe and critique a nursing in-service Observe change of shift reporting

Knowledge of the nursing hierarchy can help you assign a nursing student to:


Some points about RN Leadership: Many DON/DNS have an associate degree or are diploma

graduates. BSN prepared DON/DNS are increasing. If Master’s prepared, degree is often in business administration, not nursing.

For In-service Educator, Master’s preparation is desirable but not mandated.

An Infection Control and Rehabilitation nurse is not required. MDS Coordinator is responsible for assessment and

oversight of care planning processes; not required.

RN LEADERSHIP


Federal Regulations for Certified Nursing Assistants (CNAs)

All CNAs must receive 75 hours of training CNAs must pass a written and behavioral/performance

competency exam to be “certified.” Certification is renewed every 2 years based on hours of in

service education received. 12 hours of in-service required annually.

Mandatory topics: infection control, safety, resident rights. Individual states can require more hours for original and bi

annual re-certification.


Nursing Governance

Sits on Boards/

Committee Member

OverseesDisciplinary

Action/Terminations

Sets schedulesAwards

Promotions

Overseesperformance

evals with nurse manager

input

Hires with supervisor

Input

Makes final Decision

Director of Nursing(DON)


A Typical Day/Shift in the life of an Nursing Home (RN) Charge Nurse

• Change of shift report.• Control substance count• Check if all staff are present. Call front

office if staff are missing. Revise assignment, if necessary.

• Start med pass (2nd nurse, if assigned)• *Telephone calls re resident

appointments, tests needed, etc.• Treatments, including enteral feeding• Attend meeting/in-service• *Order and put away supplies• Write Plan of Care and/or MDS• Process discharge of resident• Admit new resident(s)• Attend to acute change of condition;

contact physician; arrange hospital transfer; prepare paperwork for same

• Clinical rounds, e.g. pressure ulcers• Prepare performance evaluations• Documentation: resident status,

“Medicare notes”, resident-specific calls made and information received.

• Orient new staff; assign CNA “buddy”• *Revise bath/shower schedule, dining

room seating, as needed• Interdisciplinary team conference:

preparation, presentation, documentation

• *Revise time schedule pursuant to staff emergency request

• Transcribe physician orders to MAR • Prepare new MAR for next 30-day

period• Contact Pharmacy regarding medication

needed STAT, med discrepancy, etc.• Write end-of-shift report • Talk with on-coming nurse; give report• Control substances count• Lunch???


Nursing Care Delivery Systems in Nursing Homes

.. Staff (RN, LPN, CNAs) are permanently assigned to the same unit in many NHs; in a growing number of NHs the CNAs have permanent resident assignment.

MedicationAides

Feeding Assistant/

Aides

RNs/LPNs

CNAs

On One Unit

Administers Medication

Provides all direct care with exception of

medications and skilled treatments

Conduct assessments; provide medications

and treatments

May have “team” nursing, led by LPN or

RN to whom staff report

Permitted by federal law; receive specific

training.


Advanced Practice Geriatric Nurses (APRNs)

200,000 APNs nationally (1)

123,000 NPs 70,000 CNSs

5,000+ ANPs are ANCC certified in geriatrics (2)

4,133 NPs 653 CNSs

By 2015, ANP & GNP programs will be combined to prepare Adult/Gerontology NPs and CNSs (3)


APRNs in Nursing Homes

< 2% of APNs work in nursing homes Most are adult and family NPs

Many NHs have APNs in their facility 63% of NH administrators report an APN in their facility (1) 20% of NHs have APNs involved in care (2)

Most APNS are not employees of the NH Employed by physician groups Employed by Evercare (3)


Role of APRNs in Nursing Homes

96

88

88

80

79

78

74

73

63

62

60

59

0 10 20 30 40 50 60 70 80 90 100

Sick/urgent resident visit

Preventive care to long-stay residents

Alternating required regulatory 30/60

Hospice care/care of dying

Care on dementia unit

Wound care

Bedside rounds with nurses

Care on short term rehab unit

Care on sub-acute unit

Bedside rounds with MDs

Interdisciplinary team meetings/rounds

In-service staff education

Percent of Respondents


Recap: Key Points about Nursing Practice in Nursing Homes

Many nursing homes operate to be “survey-ready” at all times; they adhere to basic standards of care but have little time or resources to deviate and try something new

Implementation of evidence-based care relies on nursing leadership

Higher RN staffing levels are associated with significantly improved care outcomes. Staffing is a major concern; turnover (especially among CNAs) can be over-whelming

The nursing home nurse integrates multiple kinds of knowledge and skills, engages in meaningful relationships with residents and families, and is a teacher and leader for staff

We present the following key points to consider:


Please Proceed to the following modules of the SeriesNursing Homes as Clinical Placement Sites

for Nursing Students

Overview of the Project

Module 1: An overview of nursing homes generally

Module 2: An overview of nursing in nursing homes

Module 3: Content on resident directed care and culture change

Module 4: Selecting and structuring clinical placements in nursing homes

Module 5: A case study to help faculty introduce resident directed care and culture change

Module 6: Strategies to help nursing homes position themselves as clinical placement

Nursing Practice in Nursing Homes Sarah Greene Burger, RN-C, MPH, FAAN Ethel Mitty, EdD, RN Mathy Mezey, EdD, RN, FAAN Hartford Institute for Geriatric.

Documents

nursing nursing hierarchy

nursing staffing

geriatric nursing

nursing practice

nursing acknowledgments

nursing nurse staffing

nyu college of nursing

nursing homes data