EP15: More Nursing in Nursing Homes

Jun 9, 2020

More Nursing in Nursing Homes

“Nursing homes have changed over time.”— Melissa Batchelor, PhD, RN, FNP, FAAN (04:04-04:14)

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 homes”

 – Tara Cortes, PhD, RN, FAAN

In this week's episode, you'll learn about:

• Who are the residents living in our nursing homes today?
• What are the major differences in how nursing homes are treated differently than hospitals in our healthcare system?
• What are some of the reasons why nursing homes struggle to provide quality care to frail older adults?
• Why do we need more nursing in nursing homes?
• What are the major differences in types of caregivers we collectively call “nursing staff” in nursing homes?
• What can consumers do to make nursing homes safer during COVID and what is needed post-COVID?

GUEST INFO:

Marie Boltz, PhD, RN, FAAN

• Professor at Penn State University College of Nursing. 
• Geriatric Nurse Practitioner/Nurse Researcher. 
• Her experience in nursing homes includes: as a clinician, an administrator, a researcher, and a consultant.

Charlene Harrington, Ph.D. RN, Professor Emerita

• Department of Social & Behavioral Sciences
• University of California San Francisco
• She studied nursing homes for 35 years, looked at staffing, ownership, financing legislation and regulation.

Barbara Bowers, PhD, RN, FAAN

• Faculty professor at the University of Wisconsin, Madison.
• She 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 school.

Ann Kolanowski, PhD, RN, FAAN

• Professor Emerita at Penn State College of Nursing. 
• Worked as a staff nurse in a nursing home. 
• She's been an educator and geriatric nurse researcher for the past 30 years.

Christine Mueller, PhD, RN, FGSA, FAAN

• Professor in the School of Nursing at the University of Minnesota and hold long-term care professorship in nursing. 
• She's been involved in studying nursing home care, particularly interested in factors associated with quality.

Tara Cortes, PhD, RN, FAAN

• Executive Director of the Hartford Institute for Geriatric Nursing at New York University Rory Meyers College of Nursing.
• Professor of nursing in college. 
• Many 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 Home

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 the past?

“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

Past:

• Typically, residents were somebody who needed some help with bathing, dressing, and grooming. 
• They no longer could live at home, so they came to the nursing home.
• That traditional type of nursing home resident still exists, but…

Today:

• That person today, as the population has aged, has become frailer, living to advanced age and also living with dementia. 
• These are folks who are in their 80s, 90s, and sometimes 100 plus, 
• Today 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.
• Many of our nursing homes are admitting residents directly from the nursing home who are requiring skilled or subacute care.
• You 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 (34:42-34:49)

What are some major differences in how nursing homes are treated differently than hospitals in our healthcare system?

“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, RN, FAAN

• Many 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. 
• • These 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
• Low 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
• The regulatory and payment structure for NHS is different than in acute care hospitals.

 

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 Home

So, why do we need more nursing in nursing homes?

• Inadequate Staffing
• • Prior to 2016, there was no requirement for minimum staffing standards. In 2016, the Obama administration increased the regulations for nursing homes. 
  • Before the pandemic, 75% of nursing homes in the United States did not have adequate staffing levels, causing the inferior quality of care. 
  • When the virus hit, it wasn't a surprise that many nursing homes were unable to prevent the spread of the disease throughout those facilities. 
  • Nursing homes that had low staffing and poor quality were the most likely to get the COVID-19 virus.

 

• Infection Control Standards
• • We 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. 
  • And 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 plans.

• The 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 (35:11-35:16)

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, FAAN explains: 

 

• LICENSED NURSES

 

• There 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 resident.
• • 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 university. 
  • • For example, ONLY RNs can develop and evaluate a nursing plan of care for a resident
    • Both types of RNs delegate nursing and direct care tasks to LPNs and CNAs
    • • Nursing 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.
    • RNs 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 care. 

• Licensed Practical Nurses (LPN) is another type of nurse with a training background from a technical school or community college.

 

• CERTIFIED NURSING ASSISTANTS

 

• The 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?

• RNs provide and average of 48 MINUTES of care per resident a day in the “nursing” home
• RNs in a hospital provide 10 HOURS a day in an acute care setting

What’s being done and what can I do?

Barbara Bowers, PhD, RN, FAAN shares:

 

• Center for Medicare and Medicaid Services (CMS) is forming a Commission for Safety and Quality in Nursing Homes. We need nurses with nursing home experience to be appointed to this commission.

 

• Contact your representatives to support H.R.6698 and S.3644

• H.R. 6698 Quality Care for Nursing Home Residents and Workers During COVID–19 Act of 2020 Schakowsky [D-IL-9] introduced May 5, 2020

• 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 period.
• At 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 weekly
• Reporting to State Health Departments if PPE shortage expected to occur
• Employee education on transmission of COVID19
• Two 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
• For 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 Home Compare 
• 24-hour Registered Nurse services provided – Note: Doesn’t say in-person (but it should!)
• State Survey monitoring (remotely) if positive COVID case
• Civil Money Penalties of $10K per day for any violation of these requirements
• Section repeats
• Medicaid Funding

• S.3644 Quality Care for Nursing Home Residents and Worker During COVID-19 Act of 2020 – Cory Booker [D-NJ] introduced May 7, 2020

About Melissa

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 at https://melissabphd.com/.