By Maureen Shawn Kennedy, AJN editor-in-chief
Earlier this month, AJN’s managing editor Amy Collins wrote a post about nursing homes, basing her discussion on a New York Times article by Paula Span at the paper’s New Old Age blog that examined efforts to address the inadequate number of registered nurses (RNs) in nursing homes. While federal regulations for agencies that receive Medicare or Medicaid require 24-hour nursing services, they only require an RN to be on site for eight hours daily. According to Span, 11.4% of nursing homes did not meet this requirement.
Collins found confirmation of this information in her own experiences visiting her grandmother in nursing homes:
“There always seems to be a lack of staff—and with so many residents these days suffering from varying levels of dementia and memory problems, staff are needed more than ever.”
We linked to the blog post on our Facebook page and received a tremendous number of comments on both sites. While both Span and Collins emphasized that increases in all levels of nursing personnel are needed, some LPNs responded to our post to assert that they too have valuable skills, as well as extensive experience, in this setting—and that a broader underlying problem is inadequate staffing tied to corporate cost-cutting.
Few people would argue with these assertions. Most LPNs do the best work they can despite impossible patient ratios. Most LPNs are assigned too many patients. Even so, there’s also a real need to increase the number of RNs in nursing homes. We know from research (and you can find links to some of the studies in Span’s article) that there are fewer adverse events when RNs are managing care. Many comments on Facebook and this blog drive the message home. Here’s a sampling:
“Having two large medication passes in one shift gives any nurse with 15 to 25 patients no opportunity to do what RNs do: assess, diagnose, plan, intervene, and evaluate. I don’t’ care how good you are…”
“Insurers are not recognizing that the ‘usual’ patient is different from years ago and requires a much higher level of care.”
“’Skilled nursing’ is a euphemism for ‘med-surg floor.’”
“The problem isn’t that RNs don’t want to work in LTC it’s that the LTC industry as a whole is an inhospitable environment for anyone to work in, nurse or otherwise…The industry is already so rootbound with rules and regulations that it is virtually impossible to function reasonably in this setting.”
“Nursing homes are no longer ‘rest homes’ but individual, sub-acute hospitals. Post-op orthopedic, cardiac, stroke care, along with rehab and wound care, bring with them outlandish amounts of regulations and paperwork. Add to that corporate financial officers who dictate the number of nurses and aides that can work each shift, no matter the acuity of care needed, and you have the recipe for what you find in nursing homes today…. A previous nurse mentioned 46 patients and one nurse on night shift. Of those 46, how many had orders for medications that required ‘30 minutes before (or after) meals,’ multiple insulins (long and short acting), multiple eye drops (administer individually with a wait between), multiple inhalers (also with waits)? Medicating ONE individual might mean 5–6 personal contacts! All of these must be recorded on the medication record and many must be documented on the patient’s chart.”
“Another unspoken issue is that nursing homes are not seen as a desirable workplace by young nurses or by high quality administrators. Lower pay and little room for advancement does not attract the best and brightest. Administrators walk a financial tight rope to keep the place profitable by keeping staffing at a minimum, which also does not lead to innovation or satisfied workers.”
There’s no doubt the quality in nursing homes varies widely. I’ve visited relatives in homes where residents were engaged with staff, music was playing, and there was an air of energy and care. And I’ve also been to a few that seemed ill-lit and foreboding, where there seemed to be few staff circulating among residents, and residents were mostly in wheelchairs in day rooms with TVs on, being watched by no one, or lined-up in hallways or rooms, one after the other, like a train waiting to go somewhere. I asked once what they were lined up for and was told they were waiting for the lunch room to open—in two hours’ time.
Span points out that new federal legislation has been introduced to increase RN staffing to 24 hours a day. But some nurses I’ve spoken with don’t feel that will happen. The for-profit corporations and their lobby are too strong and will block such legislation as being too expensive. As one commenter noted about the state of nursing care in nursing homes, “Is this an indication of how little we value the elderly or how greedy someone is?” Sadly, I think it’s both.