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,
New York University College of Nursing
Module 2 of Nursing Homes as Clinical Placement Sites for Nursing Students Series
Acknowledgments
This is a joint project of
With support from
Grant to the
University of Minnesota
School of Nursing
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
This project is endorsed by:
Project Steering Committee
View List of Members
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
About Module 2: Nursing Practice in Nursing
Homes
Objectives/Purpose:

Describe nurse hierarchy, leadership and
governance
At the end of this module
you will be able to:

Differentiate among nursing staffing: actual and
recommended

Analyze the delivery of nursing care in nursing
homes
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.
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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 shifts

Use Criteria to observe the extent to which a resident is
receiving rehabilitative and/or restorative nursing
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
What the Federal law (Nursing Home Reform Act NHRA,
[OBRA ’87] requires for Nurse Staffing as a minimum
RN must be on duty eight consecutive hours/day seven days a week
In nursing homes with <60 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 = 1:8;
evening=1:15; night=1:20 (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.)

© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Nursing Hierarchy in Nursing Homes
RN Director of Nursing (DON) or
Director of Nursing Services (DNS)
One RN on staff: DON. Some DON/DNS
have executive title (e.g.,
VP for Resident Care Services).
Has “support service” departments reporting
to them, e.g. housekeeping, dietary, pharmacy
RN (or LPN) Supervisor
oversees several nursing “units”
Supervisor typically has
clinical and administrative
responsibilities.
An RN (or LPN) Nurse Manager
role of head nurse with 24/7
responsibility and accountability
Nurse Manager can also be called
“Resident Care Coordinator”
or some variation.
•
Certified Nurse Assistant (CNA)
constitute 70% of nursing staff
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
RN LEADERSHIP
Some points about RN Leadership:
 Many DON/DNS have an associate degree or are diploma
graduates. BSN prepared DON/DNS are increasing.
 If Master’s prepared, degree is often in business
administration, not nursing.



For In-service Educator, Master’s 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 required.
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Federal Regulations for Certified Nursing
Assistants (CNAs)





All CNAs must receive 75 hours of training
CNAs must pass a written and behavioral/performance
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.
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Nursing Governance
Makes
final Decision
Sits on
Boards/
Committee
Member
Oversees
Disciplinary
Action/
Terminations
Hires with
supervisor
Input
Director of
Nursing
(DON)
Sets schedules
Oversees
performance
evals with
nurse manager
input
Awards
Promotions
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
A Typical Day/Shift in the life of an Nursing Home (RN)
Charge Nurse
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Change of shift report.
Control substance count
Check if all staff are present. Call front
office if staff are missing. Revise
assignment, if necessary.
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
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Clinical rounds, e.g. pressure ulcers
Prepare performance evaluations
Documentation: resident status,
“Medicare notes”, resident-specific
calls made and information received.
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 request
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???
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Nursing Care Delivery Systems in Nursing
Homes
Conduct assessments;
provide medications
and treatments
May have “team”
nursing, led by LPN or
RN to whom staff report
RNs/LPNs
On One Unit
Provides all direct care
with exception of
medications
and skilled treatments .
CNAs
Feeding
Assistant/
Medication
Aides
Aides
Administers
Medication
Permitted by federal
law; receive specific
training.
Staff
. (RN, LPN, CNAs)
are permanently
assigned to the same
unit in many NHs; in a
growing number of NHs
the CNAs have
permanent resident
assignment.
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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)
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
APRNs in Nursing Homes

< 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)
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Role of APRNs in Nursing Homes
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Recap: Key Points about
Nursing Practice in Nursing Homes
Many
We present the following
key points to consider:
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 overwhelming
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Please Proceed to the following modules of the Series
Nursing 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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing