Nursing Practice in Nursing Homes

1. Nursing Practice in Nursing Homes Sarah Greene Burger, RN-C, MPH, FAANEthel Mitty, EdD, RNMathy 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

2. Acknowledgments This is a joint project of With support from Grant to the University of Minnesota School of Nursing

3. This project is endorsed by: Project Steering Committee View List of Members

4. 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.

5. Knowledge of Nurse Staffing If you know about nurse staffing, you can assign students to: • 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

6. 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.)

7. 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

8. 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 RN Director of Nursing (DON) or Director of Nursing Services (DNS) RN (or LPN) Supervisor oversees several nursing “units” Supervisor typically has clinical and administrative responsibilities. An RN (or LPN) Nurse Manager role of head nurse with 24/7 responsibility and accountability Nurse Manager can also be called “Resident Care Coordinator” or some variation. Nursing Hierarchy in Nursing Homes • Certified Nurse Assistant (CNA) constitute 70% of nursing staff

9. 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:

10. RN LEADERSHIP 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.

11. 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.

12. Nursing Governance

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

14. Nursing Care Delivery Systems in Nursing Homes 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.

15. 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)

16. 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)

17. Role of APRNs in Nursing Homes

18. 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:

19. 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