Structuring Student Placements in the Nursing Home Mathy Mezey, EdD, RN, FAAN, Sarah Greene Burger, RN-C, MPH, FAAN Ethel Mitty, EdD, RN Hartford Institute.

Structuring Student Placements in the Nursing Home

Mathy Mezey, EdD, RN, FAAN, Sarah Greene Burger, RN-C, MPH, FAAN

Ethel Mitty, EdD, RN

Hartford Institute for Geriatric Nursing, New York University College of Nursing

Module 4 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 4: Structuring Student Placements in the Nursing Home

Select a nursing home as a clinical placements for nursing students

Design student placements in nursing homes in light of student learning goals

Organize student exposure to resident-directed care and culture change

Analyze resources that can inform student placement in nursing homes:

Resources to enhance clinical teaching in nursing homes generally

Resources specific to clinical teaching of resident-directed care and culture change

General geriatric nursing resources

Objectives/Purpose:

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

Please note that Module 4 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.


Faculty should preferentially choose nursing homes for clinical

placements that meet nationally recognized standards of high

quality care: Nursing homes with a CMS 5 or 4 Star Quality Rating

These nursing homes will be in the top 10% of nursing homes nationally and represent the highest quality of care

These nursing homes are more likely than others to have higher RN / resident staffing ratios

Nursing homes with Joint Commission accreditation Joint Commission accreditation is voluntary; related to nursing home’s

managed care relationship and healthcare network requirements

Selecting a Nursing Home as a Clinical Placement: General Recommendation 1

Click to view more information on MDS - Module 1: An overview of nursing homes generally and on Nursing Staffing, Module 2: An overview of nursing in nursing homes


Selecting a Nursing Home as a Clinical Placement: General Recommendation 2

Nursing homes with a CMS 1 Star Rating in all likelihood haveserious deficiencies in quality of care

Avoid homes with one yellow star, indicating chronic poor care,irrespective of student learning objectives

Nursing homes with CMS 2 and 3 Star Ratings are likely to havedeficiencies in important aspects of care and/or staffing

Nursing homes with many and persistent deficiencies should beAvoided

Consider the number and type of deficiencies in relationship to the student learning objectives


Options for Student Placement When Nursing Homes with High Quality Ratings are Not Geographically Accessible

Seek CMS 3 & 4 star nursing homes interested

in opportunities to improve care

Collaborate with nursing homes: Workshops for

faculty and students

Senior Center

Continuing Care Retirement Community

Naturally Occurring Retirement Community

Assisted Living


The Director of Nursing (DON) does not have a minimum of a baccalaureate degree in nursing

RNs are not on site during student placement

There is instability in nurse leadership, and nursing staff (RN; LPN; CNA) turnover is very high

Click here to learn more: Module 2: An overview of nursing in nursing homes

Nursing Faculty Concerns: Nursing Homes as a Clinical Placement


Select placements other than nursing homes Tailor student assignment to nursing home’s staffing strengths and

students’ level in the program: Use nursing home for task-oriented assignments (e.g., manual

skill acquisition). Assign student to nursing home nursing staff with at least BSN. Assign students to shadow an APN who cares for residents in the

nursing home.

Options for Student Placements When a Nursing Home with Strong RN Presence is Not Available

Click to view more information on MDS: Module 1: An overview of nursing homes generally

Click to view more information on Nursing Staffing: Module 2: An overview of nursing in nursing homes


Nursing homes engaged in culture change should be preferentially selected as clinical placement sites

Identifying culture change nursing homes Self-identified Member of:

Pioneer Network (http://www.pioneernetwork.net) Eden Alternative (http://www.edenalt.org) Greenhouse (http://www.thegreenhouseproject.org) Wellspring (http://www.wellspringis.org)

Nursing homes can be practicing resident-directed carebut not self-identify as a culture change nursing home.

Resident-Directed Care and Culture Change Nursing HomesResident-Directed Care and Culture Change Nursing Homes

Click here to view content on resident directed care and culture change: Module 3: Content onresident directed care and culture change

Click here to view a case-study on culture change and options for introducing culture change concepts when no culture change facilities are geographically available: Module 5: A case study to help faculty introduce resident-directed care and culture change


Observe and understand Resident choices and autonomy Issues of resident risk versus safety Licensed nursing role in staff and resident empowerment Leadership style

Meet with a primary CNA to learn about resident preferences, how CNAs prioritize and help the resident make decisions

Senior/APN student activity/assignment: modify and adapt resident’s care plan based on the resident’s perception of risk taking and safety needs

In absence of a culture change nursing home see module 5

Opportunities for Student Learning in Culture Change Nursing Homes

Click here to learn more about Resident directed care and culture change: Module 3: Content onresident directed care and culture change

Click here to view a case-study on culture change: Module 5: A case study to help faculty introduce resident-directed care and culture change


Types of learning objectives Learning objectives related to type of course

Learning objectives related to specific content or skills 1, 2

Health systems: Nursing Home Quality Resident attributes/assessment Diagnosis and management Leadership, staffing and organizational assessment Interdisciplinary team Resident directed care and culture change Ethical decision making Policy and reimbursement

Nursing Nursing Student Learning Objectives Learning Objectives


Assign student to evaluate overall quality of the nursing home to which they are assigned by comparing with other nursing homes. See websites: www.medicare.gov/NHCompare www.nhqualitycampaign.org

Assign student to compare state regulatory variations among states: http://www.hpm.umn.edu/nhregsplus/ Intensify the depth of assignment based on student’s level

in the program (i.e. generic juniors, seniors, graduate)

Assign students to look at web site: Nursing Home Compare http://www.medicare.gov/NHCompare http://pioneernetwork.org

Learning Objective Health systems: NH Quality Sample Student Assignments


Learning Objective Health systems: Nursing Home Quality Sample

Student Assignments (Cont’d)

Create assignments to meet student learning goals, e.g. communication, policy, interdisciplinary

Assign student to participate in family/resident care plan meeting

“Adopt a resident”: interview resident, family, interdisciplinary team members, staff to create a “collage” of the resident: history, etc. [reminiscence-type therapy] After soliciting input from nursing staff, have student prepare and

present an evidence-based in-service program (e.g., culture change, geriatric syndromes, geriatric resources)

Discussion: why did the facility get a “low” star rating? What were the deficiencies? How were they related to nursing care? How can nursing leadership/management change in order to achieve better outcomes?


Student assignments can consist of the following:

Dementia unit: meet learning objectives related to communication Sub-acute care unit: meet learning objectives related to acquiring

manual/technical skills (ventilators; tracheostomy care) Interdisciplinary team meetings: meet learning objectives related to

understanding team roles Short-stay residents: meet learning objectives for synthesis of

patient care management

Learning ObjectiveResident Attributes/ Assessment

Sample Student Assignments

For a description of resident attributes, special care units etc. see:

Module 2: An overview of nursing in nursing homes

Module 1: An overview of nursing homes generally


Assign students to compare the job descriptions of the chief nursing officer in the nursing home, the hospital, in assisted living and in home care

Assign students to compare nurse staffing (RN; LPN; CNA) in their nursing home placement with nursing home staffing nationally and in their state (content related to policy) View the Nursing Home Compare Website

Assign students to observe the role of the DON, the nurse manager, the CNA (content related to leadership)

Assign students to assess the program offered in a nursing home rehabilitation unit verses the rehabilitation program in home care or in a hospital rehab unit

Assign student to observe examples of communication within and between different categories/strata of staff (i.e. direction and type of communication)

Learning Objective Leadership, Staffing and Organizational Assessment

Sample Student Assignments


Nursing homes are ideal clinical placements to expose nursing students

to an inter-disciplinary team. 1,2

Students should have the opportunity to observe the process and

outcomes of an interdisciplinary team meeting.

The Interdisciplinary Team in Nursing Homes

Click here to view the GNEC Module on the interdisciplinary team

For more information, click to view Module 1: An overview of nursing homes generally


Observe the role of nurses on the interdisciplinary team Present a resident issue at team meetings Speak with and “shadow” key members of the interdisciplinary team Meet with resident/family prior to team meeting to learn their wishes

or concerns Meet with the resident’s CNA to get their view on care needs and/or

solutions to problems

Learning Objective: Interdisciplinary teamsSample Student Assignments

AGS Geriatric Competences for Inter-disciplinary practice


For more information, click on the following links:



Determine a resident’s capacity to execute an advance directive Evaluate the extent of resident involvement in their “everyday decisions”

(e.g., bathing; eating) Understand how decisions are made to transfer a resident to the hospital Senior level student: In discussion with the resident, evaluate the benefit and

burden of potential treatments/interventions1

Learning Objective: Ethics and Decision Making Sample Student Assignments

For more information click to view Module 2: An overview of nursing in nursing homes


Speak with social workers regarding criteria for nursing home admission and discharge

Meet with the MDS coordinator to understand how assessment drives reimbursement

Evaluate the quality improvement data collected and distributed to the interdisciplinary team

Read and evaluate the NH current quality improvement plan and/or study APN Student Assignment: Evaluate/describe how advocacy groups like

NCCNHR and Pioneer Network work to change policy to improve care and quality of life

Learning Objective: Policy and ReimbursementSample Student Assignments



For more information click on the following links:


Faculty should: Learn/understand the mission of the nursing home Seek unit staff ‘buy-in”:

to the goal and purpose of the placement to assure their awareness of students’ level of knowledge and skills

Learn how nursing staff organize their time to provide resident care Identify opportunities for electronic communication Recognize staff and students through established joint “rituals” (e.g.

graduations; awards; end of semester luncheons; nurses week celebrations)

If possible, spend several hours at the nursing home to: Identify professional roles in the nursing home Understand decision-making practices regarding resident care Understand the culture – and routine(s) – of the nursing home, including time and

location of interdisciplinary team conferences Learn the EMR system/ process with which the students will be

interacting/involved

Adapted with permission of CS Aron., Illinois State University, Mennonite College of Nursing

Enhancing Communication with the Nursing Homes to Strengthen the Student Learning Environment


Related Resources for Clinical Teaching in Nursing Homes

Weekly Reflection Questions UNC Charlotte School of Nursing

http://nursing.uncc.edu

Elder Project Fairfield University School of Nursing

http://www.fairfield.edu/son http://www.fairfield.edu/son

ECLEPs Project College of Nursing, Oregon Health Sciences

Universityhttp://www.ecleps.org

View General Geriatric

Nursing Resources


Recap: Key Points about Structuring Student Placement in the Nursing Home

All nursing homes are not alike

Use objective criteria as to quality and staffing to help you select a nursing home for student placement

Choose programs within a nursing home to meet specific learning objectives

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 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

Structuring Student Placements in the Nursing Home Mathy Mezey, EdD, RN, FAAN, Sarah Greene Burger, RN-C, MPH, FAAN Ethel Mitty, EdD, RN Hartford Institute.

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