Presented by: Paula Lee RN Community Nurse Leader Heisinger Bluffs Jefferson City, MO

1. Consistent AssignmentsAdapted from David Farrell MSW, NHAby Alexis Roam, RN, PrimarisandJennylyndeRenteria-Packham RN, MSN, CDONAwww.nhqualitycampaign.org Presented by: Paula Lee RN Community Nurse Leader Heisinger Bluffs Jefferson City, MO

2. What Is Consistent Assignments? • The same staff caring for the same residents 80% of the time • Consistent assignments are not “permanent” assignments • Permanent assignments implies staff will never have to rotate. • Consistent assignments allows for some movement as needed.

3. The Impact of Consistent Assignments • Improves clinical outcomes • Supports relationship development • Decreases call-ins and turnover • Supports person-centered care • Overall cost decrease as quality and satisfaction

4. Polling question How many participants are using consistent assignments? Yes No Not sure

5. Why Even Try?

6. Why even try? For our Residents! • Bottom line for all “care givers” is what is best for the resident. • Much supporting evidence that consistent caregivers equals the best care. (David Farrell’s work) • Families report greater satisfaction with consistent caregivers. • Resident quality of life greatly increased.

7. Why even try? For our Staff! • Our staff want to give the best possible care. • Much supporting evidence that consistent caregivers equals the best care. (David Farrell’s work) • Empowering staff leads to … • Better work environments • Consistent assignment promotes ownership of the care provided. • A positive workplace will hold good staff longer than any other benefit.

8. Why even try? For our business! • Increased resident/family satisfaction + increased staff satisfaction = increased revenue! • More word-of-mouth recommendations from staff and families • Longer employee retention=decrease in HR costs • ALL other goals will be positively affected by consistent assignment.

9. PRE-REQUISITE FOR PERSON-CENTERED CARE • Consistent staffing is a “pre-requisite” for individualized/person-centered care. • The core values of culture change include:

10. Core Values of CULTURE CHANGE • Respect • Relationships • Community • Empowerment • Choice All five are impacted by consistent staffing and consistent staffing provides a frame work upon which the core principles can be built. The Pioneer Network: Five Core Principles of Culture Change

11. Evidence: Decreases Turnover • Rotating staff made CNAs feel less valued for their skill and knowledge • CNAs defined ‘good care giving’ as based on the establishment and maintenance of good relationships with residents • CNAs felt any disruption to these relationships was detrimental to the quality of the care provided and the quality of residents’ lives • Even with verbal recognition of a job well done, CNAs felt the management’s staffing decisions were contradictory to the acknowledgement. Bowers BJ. “Turnover Reinterpreted: CNAs Talk About Why They Leave.” Journal of Gerontological Nursing 29.3 (March 2003): 36-44.

12. Evidence: Improves Outcomes, Satisfaction • Compared two nursing homes with permanent assignments to two nursing homes with rotating assignments • Residents living in permanent assignment nursing homes received significantly higher ratings of personal appearance and hygiene than residents in rotating assignment homes • Nurse aides working in permanent assignment homes reported higher job satisfaction than those working in rotating assignment homes Burgio LD, Fisher SE, Fairchild JK, Scilley K, Hardin M. “Quality of Care in the Nursing Home: Effects of Staff Assignment and Work Shift.” The Gerontologist 44.3 (2004): 368-377.

13. Improves Outcomes, Satisfaction (cont’d) • Evaluate effectiveness of primary nursing assignment • Care Outcomes • One year after implementation - 75% reduction in the incidence of decubitus ulcers • 18% decrease in patient death rate • 11% increase in patient discharge to lower levels of care • Two years later - 36% increase in the number of ambulatory patients • Nursing Staff Outcomes • One year after implementation - turnover rate declined by 29% • After implementation nurses reported feeling 26 % more accountable Campbell S. “Primary nursing: It works in long-term care.” Journal of Gerontological Nursing 8 (1985): 12-16.

14. Evidence: Decreases Turnover (cont’d) • Focused on the responses from a questionnaire given to nurse assistants: • Effects on tenure: • Longer tenure ensures that staff becomes more familiar with the residents • Bonding occurs • Responsibility for the residents is enhanced • Quality of care improves.” Changing assignments: Changing patient assignments daily was correlated with those nursing assistants who were planning to leave Caudill M. “Turnover Among Nursing Assistants: Why They Leave and Why They Stay.” The Journal of Long-Term Care Administration 29 (1991–1992): 31.

15. Decreases Turnover (cont’d) • Staff input: Of those nursing assistants who said they had input into the planning of care for their patients, 84% planned to stay in their jobs • Relationships: When asked ‘What is most important to you?’ • The nurse assistants planning to stay in their jobs reported “their own personal feelings for their patients” were most important to them. Changing assignments: Changing patient assignments daily was correlated with those nursing assistants who were planning to leave Caudill M. “Turnover Among Nursing Assistants: Why They Leave and Why They Stay.” The Journal of Long-Term Care Administration 29 (1991–1992): 31.

16. Overall Impact • Advantages with implementing primary nursing care: • Residents feel more comfortable and secure • Resident care is improved with increased staff responsibility for care they provide • Increase in job satisfaction • Staff can anticipate residents’ needs • Staff is accountable for residents, and it takes pride in resident improvements and successes Goldman BD. “Nontraditional staffing models in long-term care.” Journal of Gerontological Nursing, 24 (1998: 29-34.

17. Impact on Turnover (cont’d) • Goal: Decrease the turnover rate to reduce costs of orientation, education and hiring new employees • Changes in staffing assignment, job satisfaction, motivation and performance • Benefits: • An increase in productivity of nurse aides • Good method of measuring productivity • Good method of orienting nurse aides Patchner MA. “Permanent assignment: A better recipe for the staffing of aides.” Successful nurse aide management in nursing homes Phoenix, AZ; Oryx Press, 1989: 66-75.

18. Impact on Person-Centered Care(cont’d) • Family Member Perspective • Personal empathy – know my mom as a person • Knowing only comes with consistency • Facilitates getting to know and trust caregivers • Helps to know who to go to with questions • Gives family members peace of mind Mary Lescoe-Long and Michael Long: “Identifying Behavior Change Intervention Points to Improve Staff Retention in Nursing Homes.”

19. COST OF TURNOVER • National Averages estimate from $2500.00 to $4500.00 per employee. • 100 bed facility- 90 employees x 123% roughly hire 111 new employees a year X $2,500.00 per employee = $276,750.00 annualized cost of turnover for this facility or $7.58 ppd cost!

20. Consistent Assignment: • Top Five Stressors • Preventing Falls • Stubborn Residents • Terminal Residents • Depressed Residents • Death as Emotional Stress • Rotating Assignment: • Top Five Stressors • Low Wage • Abusive Residents • Heavy Workload • Disagreements w/ Coworkers • Lack of Staff

21. C.N.A TESTIMONIALS • “For me as the caregiver, I can pick up on conversations where we left off from the day before and they still remember what we were talking about.” • You can tell by the look on their face that they are comfortable and glad to see a familiar face on a day to day basis. They remember your name and things about your life. We feel like a family.” C.N.A.’s from Wyndcrest Nursing Home in Clinton, Ia.

22. Putting a Plan into Action

23. Pick the starting area: one floor, unit, hall, etc. • Gather the data which shows current staffing patterns. • Find a champion both in the direct care staff and leadership. • Promote sharing and don’t be afraid of feedback. • Don’t place blame and don’t look for excuses. • Last but not least…..

24. Don’t forget the resident!

25. Closing Thoughts

26. References Bowers BJ. “Turnover Reinterpreted: CNAs Talk About Why They Leave.”Journal of Gerontological Nursing 29.3 (March 2003): 36-44. Bowers BJ, Esmond S, Jacobson N. “The Relationship Between Staffing and Quality in Long-Term Care Facilities, Exploring the Views of Nurse Aides.”Journal of Nursing Care Quality14.4 (July 2000): 55-64. Burgio LD, Fisher SE, Fairchild JK, Scilley K, Hardin M. “Quality of Care in the Nursing Home: Effects of Staff Assignment and Work Shift.”The Gerontologist 44.3 (2004): 368-377. Campbell S. “Primary nursing: It works in long-term care.”Journal of Gerontological Nursing 8 (1985): 12-16. Caudill M. “Turnover Among Nursing Assistants: Why They leave and Why They Stay.”The Journal of Long-Term Care Administration 29 (1991–1992): 31.

27. References (cont’d) Cox CL, Kaeser L, Montgomery AC, Marion LH. “Quality of life nursing care: An experimental trial in long-term care.”Journal of Gerontological Nursing 17 (1991): 6-11. Eaton S. “Beyond Unloving Care Linking Human Resource Management and Patient Care Quality in Nursing Homes.”International Journal of Human Resource Management 3 (June 11, 2000): 591-616. Goldman BD. “Nontraditional staffing models in long-term care.” Journal of Gerontological Nursing 24 (1998): 29-34. Mueller C. “A Framework for Nurse Staffing in Long-Term Care Facilities.” Geriatric Nursing 21.5(September-October 2000): 262-7. Patchner MA. “Permanent assignment: A better recipe for the staffing of aides.” Successful nurse aide management in nursing homes Phoenix, AZ; Oryx Press, 1989: 66-75.