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 lt60
  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 18 evening115 night120 (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
Nursing Hierarchy in Nursing Homes

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

9
Knowledge of the Nursing Hierarchy
Knowledge of the nursing hierarchy can help you
assign a nursing student to

• 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

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 Masters prepared, degree is often in business
• administration, not nursing.
• For In-service Educator, Masters 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/performanc
  e
• 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
A Typical Day/Shift in the life of an Nursing
Home (RN) Charge Nurse

• 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???

• 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

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

• lt 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