Jun 9, 2020
More Nursing in Nursing Homes
“Nursing homes have changed over
time.”— Melissa Batchelor, PhD, RN, FNP, FAAN
Melissa Batchelor has been
involved with nursing home care since 1996 and as someone who's
been in the business for quite some time, she can tell that nursing
homes have truly changed over time. Today, we're going to talk
about nursing in an age-friendly nursing home, along with Melissa's
friends and colleagues, who have very extensive backgrounds and
histories in nursing and home care.
“As a country, we must make
a serious investment in the systems that care for older people.
That means nursing homes need to be recognized and reimbursed as a
vital part of the healthcare system, and as equal partners in the
health care system. Let's continue to support any continuing
education and leadership training for registered nurses in nursing
– Tara Cortes, PhD, RN, FAAN
In this week's episode, you'll
are the residents living in our nursing homes today?
are the major differences in how nursing homes are treated
differently than hospitals in our healthcare system?
are some of the reasons why nursing homes struggle to provide
quality care to frail older adults?
do we need more nursing in nursing homes?
are the major differences in types of caregivers we collectively
call “nursing staff” in nursing homes?
can consumers do to make nursing homes safer during COVID and what
is needed post-COVID?
Marie Boltz, PhD, RN,
- Professor at Penn State University College of
- Geriatric Nurse Practitioner/Nurse
experience in nursing homes includes: as a clinician, an
administrator, a researcher, and a consultant.
Charlene Harrington, Ph.D. RN,
- Department of Social & Behavioral
- University of California San
studied nursing homes for 35 years, looked at staffing, ownership,
financing legislation and regulation.
Barbara Bowers, PhD, RN,
- Faculty professor at the University of
has spent over 30 years as a teacher, researcher and clinician in
long-term care settings.
- Worked as a certified nursing assistant (CAN)
in nursing homes to put herself through undergraduate nursing
Ann Kolanowski, PhD, RN,
- Professor Emerita at Penn State College of
- Worked as a staff nurse in a nursing
been an educator and geriatric nurse researcher for the past 30
Christine Mueller, PhD, RN,
- Professor in the School of Nursing at the
University of Minnesota and hold long-term care professorship in
been involved in studying nursing home care, particularly
interested in factors associated with quality.
Tara Cortes, PhD, RN,
- Executive Director of the Hartford Institute
for Geriatric Nursing at New York University Rory Meyers College of
- Professor of nursing in
years of her career were spent in the hospital, in the nursing
administration, and most of her last twenty years have been very
focused caring for older adults with a particular emphasis and
interest in long-term care.
Part One of “Nursing” In an Age-Friendly Nursing
Nursing homes are where people
who have very complex chronic conditions and functional
amputations, live in the hope that they can receive care that's
going to give them a good quality of life. And not just custodial
care, but sadly, nursing homes and long-term care, in general, are
not seen as an integral component of our healthcare system. Here's
a little snapshot about how nursing homes are different today than
they used to be according to Dr. Marie Boltz:
How are nursing homes different today than they were in
“Many folks think that
nursing home care is unexciting and doesn't vary from day to day.
But as you can see, it's very complex because the residents with
multiple comorbidities and conditions need extensive assessment and
care management. After all, when they do become ill, their symptoms
are often subtle and very hard to recognize”. – Marie Boltz,
PhD, RN, FAAN
- Typically, residents were somebody who needed
some help with bathing, dressing, and grooming.
no longer could live at home, so they came to the nursing
traditional type of nursing home resident still exists,
person today, as the population has aged, has become frailer,
living to advanced age and also living with
are folks who are in their 80s, 90s, and sometimes 100
these residents have a lot of comorbidities, high rates of
cognitive impairment, and sometimes serious mental illness and/or
substance abuse issues overlaid on top of that.
of our nursing homes are admitting residents directly from the
nursing home who are requiring skilled or subacute
can imagine the combination of these with trying to provide a
home-like environment, and honoring preferences can challenge
today’s nursing home staff.
“People who work in long-term care facilities and
geriatrics aren't there for the money, but because they actually
care.” — Melissa Batchelor, PhD, RN, FNP, FAAN
What are some major differences in how nursing homes are
treated differently than hospitals in our healthcare
“There's a tremendous gap in
nursing leadership in nursing homes. Most Directors of Nursing do
not have education beyond their basic nursing program. This is
unlike what happens in acute care settings where nursing leadership
typically has a graduate education and certification.”
- Ann Kolanowski, PhD,
of the professional nurses who are in nursing homes are not
involved in direct care – this work is primarily done by Certified
Nursing Assistants (CNAs).
- Professional nurses are not practicing to the
full scope of their license.
nurses may be involved in tasks like passing medications or
administering treatments rather than doing the type of work that
only a professional nurse can do.
- Inadequate training resulting in a lack of
expertise for recognizing and managing complex problems
pay – there is a tremendous difference in what a nurse makes in a
NHS compared to a hospital or medical center
- Little or no sick leave
regulatory and payment structure for NHS is different than in acute
All of this contributes to a
very high rate of staff turnover and an inability to sustain
positive change” - Ann
Kolanowski, PhD, RN, FAAN
Part Two of “Nursing” In an Age-Friendly Nursing
So, why do we need more nursing in nursing
- Inadequate Staffing
to 2016, there was no requirement for minimum staffing standards.
In 2016, the Obama administration increased the regulations for
- Before the pandemic, 75% of nursing homes in
the United States did not have adequate staffing levels, causing
the inferior quality of care.
the virus hit, it wasn't a surprise that many nursing homes were
unable to prevent the spread of the disease throughout those
- Nursing homes that had low staffing and poor
quality were the most likely to get the COVID-19 virus.
- Infection Control Standards
also know that before the virus, 63% of all the nursing homes did
not meet the infection control standards and were given
deficiencies by the state surveyors.
again, that was primarily because it's directly related to the lack
of registered nurse staffing in nursing homes who are essential for
developing infection control plans and implementing those
Impact of For-Profit Nursing Homes
“Over 70% of nursing homes
in the United States are for- profit. These nursing homes are
trying to make money for their owners or shareholders. And many of
them are big chains. One of the ways they do that is by keeping the
staffing levels low because they're the most expensive type of
nurse and their overall staffing. And this is why it has
contributed to a persistent chronic low staffing in nursing homes
around the country” - Charlene Harrington, Ph.D., RN, FAAN
“Everybody deserves a safe environment.” —
Melissa Batchelor, Ph.D., RN, FNP, FAAN
There are different types of caregivers collectively
referred to as “nurses”. Can you explain the differences in these
types of caregivers?
Christine Mueller, Ph.D., RN,
are two types of licensed nurses in nursing homes and each has a
different “scope of practice”. That means each role within the
nursing team has different things they can do for a
- Registered Nurses (RN) who can have an
Associate Degree from a technical school or community college; or a
Bachelor’s of Science in Nursing (BSN) from a
example, ONLY RNs can develop and evaluate a nursing plan of care
for a resident
types of RNs delegate nursing and direct care tasks to LPNs and
care is usually
delegated to LPNs and includes passing medications, doing
assessments of residents, reporting findings to the RN,
implementing a nursing plan of care.
- Direct care
is usually delegated to CNAs and
includes directly helping a resident to eat, use the bathroom, get
dressed, toileting, bathing and grooming.
can do all of the duties LPNs and CNAs can do - but rely heavily on
these members of the healthcare team to deliver nursing and direct
- Licensed Practical Nurses (LPN) is another type
of nurse with a training background from a technical school or
- CERTIFIED NURSING ASSISTANTS
majority of direct care provided in nursing homes is delivered by a
Certified Nursing Assistant. Direct
care is a term that
means directly helping a resident to eat, use the bathroom, get
dressed, toileting, bathing and grooming.
DID YOU KNOW?
provide and average of 48 MINUTES of care per resident a day in the
in a hospital provide 10 HOURS a day in an acute care
What’s being done and what can I do?
Barbara Bowers, PhD, RN, FAAN
- Improving Quality of Care in SNFs and NFs by
adding a Full-time Infection Control with specialized training in
prevention and control.
- Residents who elect to leave the facility and
live with family can be readmitted with180 days of emergency
least 72-hours notice of discharge or transfer to LAR
- Weekly testing of residents for COVID19 and
reporting - OR if testing kits are not available, daily screening
until sufficient test kits obtained.
- Adequate staffing to assist communication with
family members through email, phone calls, virtually at least
- Reporting to State Health Departments if PPE
shortage expected to occur
- Employee education on transmission of
weeks of paid sick leave
- Employee testing prior to each shift and
reporting – OR if testing kits are not available, daily screening
until sufficient test kits obtained
both staff and employees: Daily reporting to CMS of confirmed or
suspected COVID19 cases; Number of deaths; amount of PPE and
projected needs; staffing levels (using existing PBJ); number of
residents and staff tested; notification of residents, family
members, and employees with 12 hours of a positive case or death;
new onset of symptoms in 3 or more residents or employees reported
within 72 hours;
- Information should be made available on Nursing
- 24-hour Registered Nurse
services provided –
Note: Doesn’t say in-person (but it should!)
Survey monitoring (remotely) if positive COVID case
Money Penalties of $10K per day for any violation of these
- Section repeats
- Medicaid Funding
I earned my Bachelor of Science
in Nursing (‘96) and Master of Science in Nursing (‘00) as a Family
Nurse Practitioner (FNP) from the University of North Carolina
Wilmington (UNCW) School of Nursing (SON). I truly enjoy working
with the complex medical needs of older adults. I worked full-time
for five years as FNP in geriatric primary care across many
long-term care settings (skilled nursing homes, assisted living,
home and office visits) then transitioned into academic nursing in
2005, joining the faculty at UNCW SON as a lecturer. I obtained my
PhD in Nursing and a post-Master’s Certificate in Nursing Education
from the Medical University of South Carolina College of Nursing
(’11) and then joined the faculty at Duke University School of
Nursing as an Assistant Professor. My family moved to northern
Virginia in 2015 and led to me joining the faculty at George
Washington University (GW) School of Nursing in 2018 as a (tenured)
Associate Professor where I am also the Director of the GW Center
for Aging, Health and Humanities. Find out more about her work