Nursing Home Staffing – Impacts on Patient Care

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The U.S. Census Bureau’s National Institute on Aging has projected there will be over 1,745,300 individuals, over age 65, residing in the United States by the year 2030. This projection will account for 19.6% of our total population. This fact, coupled with the issue of rising medical costs and the failure of Medicare to cover long term and nursing homes, raises great concern over the care of the elderly in the very advance future. This research paper will outline a brief history of nursing homes, the training proposed and needed for CNA staff, the issues with regard to reimbursements of CNA training and errors and implications of report keeping. These issues are of great importance to our country’s healthcare system and should be examined closely to ensure the aging are cared for in an appropriate manner. 

The American Heritage Dictionary defines a nursing home as “a private establishment that provides living quarters and care for the elderly or chronically ill”. In the early 20th century, to be former and frail might have been a more frightening experience than what it is today. Although still frightening, care for the elderly has improved dramatically. With it’s onset, in 1907, the nursing home offered very little in terms of pay. Some pay rates were as low as $50 a month for nursing staff. During the Huge Depression, almost 62% of almshouse residents were over age 65 and 30% of those were in need of nursing care. Today, we find the staff is paid somewhat better but control measures for care are not adequate to ensure the aging population is care for appropriately. 

In recent research materials, we find the predominant staffing within the nursing home setting is comprised of Certified Nursing Assistants (CNA). CNA’s, historically, are found to be individuals who may not have progressed well through aged classroom settings. As a result, they have great difficulty in succeeding in complex testing situations. Consequently, testing for CNA certification is shown to be remedial when compared to the level of responsibility a CNA may be entrusted with. Not all states require clinical training. Unfortunately, it is has been found that an individual pursing a CNA certification may perform well in a more hands-on approach to their training versus a classroom setting. Federal law only requires 75 hours of training which may include a combination of both classroom and clinical settings. Proposals have been made in an effort to form a more standardized level of training whereby the CNA will be able to transfer their skills from one state to another without much difficulty. By doing so, this would allow the CNA to enjoy a more versatile and open job market. In today’s setting, the CNA will undergo the necessary testing and clinical training only required for the particular state in which they reside. As a result, they tend to lack in the area of compassion and empathy and are rather uneducated in terms of medical needs and habits of their patients. As with most professions, the individuals within the profession want to feel as if they are making an impact in their daily interaction with the resident of the home. Because of this, suggestions have been made to establish not only a standardized core curriculum for the states, but to also augment the program with modules. Augmented modules will further enhance, and reward, those CNAs who depart beyond their standard scope of their license and work in a more specialized field. An example might be Hospice, Assisted Living or Home Care specializations. The goal for these types of programs would be to add value and self worth to the licensed CNA and provide incentives for those who achieve a career for themselves. Studies have shown that individuals who place value in their careers tend to care more about their work product. In this case, the patient outcomes would improve. 

With establishment of training incentives, we must examine the method in which education and training is paid. Currently, the states provide very slight in terms of reimbursement to nursing home facilities that provide further education to their staff. In a Center for Medicaid/Medicare Services study, it was found that most facilities are reimbursed at the same percentage at which they care for Medicaid patients. In other words, if the facility has a 75% ratio of Medicaid recipients to non-recipients, then the state would reimburse that facility 75% of the expenses for training. With those types of reimbursement rates, we find there isn’t much incentive for the facilities to offer further education to their staff. In addition to these factors, it has also been definite, through studies, that nursing home staff is not well educated in pain assessment nor management of the wound. In fact, in one study, more than 68% of the patients reported a negative experience in terms of the CNA assessing their afflict symptoms and management. As mentioned previously, when education and clearly defined augmented curriculums are presented, the CNA will have a tendency to care more about the work they create. Incentives for continuing their education should be provided with a 100% reimbursement rate program from the CMS budget. Additionally, it has been suggested that attendance at regional and national conferences, foreign language courses and interactive classroom training should be encouraged among the staff. Mentor programs with standardized trainer qualifications should also be considered in addition to the creation of a more “core” care program. By this we mean the CNA will become the primary caregiver for a particular spot of patients in order to learn the patient’s habits and daily care needs. By creating a core program, the CNA may be assessed on their ability to provide care rather than performing processing tasks. With these considerations, we then examine the need for better record keeping and auditing to ensure the programs are in place and functioning to provide better patient outcomes in our nursing homes. 

In recent assessments, it has been found that the culture of record keeping within our nursing homes is extremely unsuitable. At present, there has not been a federally standardized method for auditing data quality among patient records. Some studies even suggest the records of daily care may be erroneous even if the CNA is working with the best of intentions. In one study of nursing home facilities, it was found that 41.2% of the residents reported wound with their first assessment and then unexcited reported the same level of pain and, in some cases, worse distress by their second assessment. In another study of 983 nurses, it was reported that only about 46% of drug dispensing errors are reported yet 93% of these same nurses know what constitutes a drug error. When questioned further, nursing home staff acknowledges they fail to report for fear for management reactions and fear of co-worker reactions. Strangely enough, however, 53% state they did not report an error because they didn’t know it was an error at all. Because of budget constraints within the facilities, there is very little incentive to assess CNA quality of care. At best, they may be only assessing processes for completion. Suggestions have been made to begin a program whereby third party assessments are done and the results of those assessments are made public to both management and consumers of the nursing home. Additionally, some states are currently evaluating the value of installing “granny cam” into the nursing homes in an effort to visually monitor the level of care a patient may receive. Advocates for these programs state they will prevent and point to abuse and neglect however there is a concern of the patient’s right to privacy. To date, only Texas and New Mexico have provided state regulations regarding such cameras. It is felt that this will encourage staff perceptions when caring for patients, possibly increase the number of staff members and improve the level of training both within and outside of the nursing home setting. 

Finally, we examine the quality of life for the patients in nursing homes. Quality of life can be defined in many terms such as comfort, affection and stimulation. A patient in a nursing home, historically, loses these most fundamental elements needed for a good quality of life. When entering into a nursing home, most patients begin to lose their resources and, thus, rely on the CNA and other nursing home staff to provide the most basic of their needs. With “care focused” staff, rather than “process driven” staff, we launch the first steps toward assisting the nursing home patients to realize the basic resources they so desperately need to sustain life. With a shortage in nursing staff, or ill-trained staff, we find the quality of life for the nursing home resident significantly decreases. With admission, each patient should be evaluated and categorized into different subgroups based on their health status. In other words, patients with severe dementia should be provided a different plan of resource delivery than a patient without dementia. This provides a more individual idea to promote the care and quality of life for the patient and further enhances the career satisfaction of the CNA charged with the responsibility of caring for that patient.
In conclusion, it is my thought that the nursing home regulations, standards and methods of care should be made a large portion of our legislatures objectives. With the aging population, the United States simply can not afford to allow our elderly to continue to suffer without the most basic care and, even more importantly, a mechanism to monitor the care level received. Without this, we will create a national epidemic and financial crisis for our country. 1.7M individuals who worked for this country will potentially be affected, adversely, by the current nursing home status. We owe these individuals the care they so rightly are entitled to as members of our society who deserve improved patient outcomes.