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Nursing Practice in Nursing Homes


Nursing Practice in Nursing Homes Sarah Greene Burger, RN-C, MPH, FAAN Ethel Mitty, EdD, RN Mathy Mezey, EdD, RN, FAAN Hartford Institute for Geriatric Nursing, – PowerPoint PPT presentation

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Title: Nursing Practice in Nursing Homes

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
This is a joint project of
With support from
Grant to the University of Minnesota School of
This project is endorsed by
  • Project Steering Committee
  • View List of Members

About Module 2 Nursing Practice in Nursing Homes
  • Describe nurse hierarchy, leadership and
  • Differentiate among nursing staffing actual and
  • Analyze the delivery of nursing care in nursing

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.
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
  • Use Criteria to observe the extent to which a
    resident is receiving rehabilitative and/or
    restorative nursing

What the Federal law (Nursing Home Reform Act
NHRA, OBRA 87 requires for Nurse Staffing as a
  • 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.)

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

Nursing Hierarchy in Nursing Homes
  • Certified Nurse Assistant (CNA)
  • constitute 70 of nursing staff

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

  • Some points about RN Leadership
  • Many DON/DNS have an associate degree or are
  • 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

Federal Regulations for Certified Nursing
Assistants (CNAs)
  • All CNAs must receive 75 hours of training
  • CNAs must pass a written and behavioral/performanc
  • 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.

Nursing Governance
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
  • 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
  • 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
  • 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

Nursing Care Delivery Systems in Nursing Homes
Conduct assessments provide medications and
May have team nursing, led by LPN or RN to whom
staff report
Permitted by federal law receive specific
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)

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)

Role of APRNs in Nursing Homes
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
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
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