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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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
This project is endorsed by:
Project Steering CommitteeView List of Members
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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.
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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:
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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.)
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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:
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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.
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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)
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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???
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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.
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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)
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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)
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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:
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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