This article explores three primary care staffing approaches that can be implemented successfully in long-term care facilities. Five continuing care retirement communities in a not-for-profit long-term care multi-facility system participated in a survey about staffing models that provided some of the following information.
FOLLOWING THE ACUTE CARE MODEL
Traditionally, nursing homes have been modeled after hospitals. Their physical plants reflect hospital environments with double-loaded corridors and semiprivate rooms which include two parallel beds, one near the window and the other closer to the bathroom. Large nurses' stations with countertops which physically separate staff from residents, loud speakers, and shiny tile floors are regular features of both acute and long-term care facilities.
DESCRIPTION OF STAFFING METHODS
Staffing of acute care nursing departments usually follows one of four basic methods:
* Functional or hierarchical.
* Case management.
* Primary nursing.
The staffing structure of long-term care nursing departments usually follow the most traditional hospital style - the functional or hierarchical model.
The functional or hierarchical staffing model is the fragmentation of service delivery in a centralized system. The assignment of procedures and tasks to nursing staff members is usually based on their education and experience. In long-term care facilities, Certified Nursing Assistants (CNAs) are responsible for assisting residents with activities of daily living (ADLs), and their assignments rotate frequently. Licensed practical nurses (LPNs) administer medications and treatments, and RNs or LPNs in charge of the shift address assessments, documentation, and care planning functions.
PRIMARY NURSING: CERTIFIED NURSING ASSISTANTS
A second acute care method is the team-based model, one of shared responsibility and accountability among team members for a specific group of residents. Resident assignments change frequently.
The third, a case management staffing model, is the provision of total care to a resident by one nurse per shift without any 24-hour oversight responsibility. Information regarding resident conditions is communicated from one shift to the next.
The literature offers many descriptions of the fourth method - primary nursing care. According to Nehls, Hansen, Robertson, and Manthey:
One nurse is given complete responsibility for the nursing care of a small group of patients who become "her" patients (1997, p. 2).
primary nursing is a series of nursing activities performed on behalf of a patient and/or the patient's family by the same, specifically assigned RN who is answerable both to the patient and to the administration of the institution for the outcomes of those activities (1980, p. 5).
Gordon, Weisman, Cassard, and Wong state, "a key strategy in the professional practice model" was initiated at Johns Hopkins Hospital where
a primary nurse holds 24-hour responsibility and accountability for a patient's nursing care plan throughout his or her length of stay and has increased decision-making authority (1995, p. 206).
For consistency, the description used for this article is
primary nursing is based on the principle that every patient is assigned an individual nurse who will plan, evaluate, and periodically administer his nursing care from his admission through his discharge (Zander, 1977, p. 19).
This description requires modification because in long-term care the caregiver may or may not be a licensed nurse. In all long-term care facilities RNs or LPNs assure the care plan is followed on a 24-hour basis, but CNAs or Resident Service Assistants may actually be the primary caregiver.
Before World War II, the case management staffing structure was common. Thereafter, nurses were not as plentiful, and other structures were adopted to meet evolving needs and demands. Today, the breakdown of nursing staff in acute care facilities tends to include proportionately more licensed nurses and fewer nursing assistants; however, in the current changing health care environment, this may not be the case for some hospitals.
In the long-term care field, CNAs comprise the largest portion of the nursing staff and deliver the hands-on care (McAiney, 1998). In addition to the director of nurses, and depending on the size of each unit, other nursing staff usually include a charge nurse or nurse manager with responsibility to oversee and direct the functions of the staff on the unit and one or more LPNs to administer medications and provide treatments. In most situations, the licensed staff remains constant on the unit but the nursing assistants rotate assignments on a monthly, biweekly, weekly, or in some cases, even a daily basis. Proponents of this model agree staff will be less apt to develop close attachments with residents. Objectors argue that only sensitive people should be caring for our elderly population in nursing homes so attachments often do and should occur.
Primary care nursing is a concept that can be altered, fine-tuned, and individualized to meet residents' specific needs and that uses available resources in each long-term care facility. Regardless of which primary nursing approach is used, it is by far the superior staffing model for longterm care. A supportive, homelike environment exists when residents and staff build strong relationships and when residents' needs can be responded to in a timely, consistent manner. In fact, staff who know the residents well can often anticipate problems before they occur and intercede before they become fullblown crises. Residents, especially those with dementia, feel more secure with a consistent caregiver; their care is improved, and staff is more accountable for their residents, taking particular pride in resident successes and improvements. Job satisfaction also is improved with this greater responsibility, and the primary caregiver, whether a CNA or licensed nurse, is recognized as an extremely important member of the residents' health care team.
PRIMARY NURSING WITH NURSING ASSISTANTS
Permanent assignments of nursing assistants to residents has been shown to produce better outcomes for both staff and residents. Nursing assistants feel more of a connection with residents because of the increased continuity of care they provide to them with this model (Teresi et al., 1993). In this first approach, CNAs are primary caregivers for seven to eight residents on both the day and evening shifts. The LPNs and RNs function in the capacities of medication/treatment nurses and nurse managers, respectively. The main difference in this model from the functional one is that nursing assistants do not rotate assignments. Although there was initial resistance to this change in facilities that made the transition, each found a greater sense of responsibility resulted with increased job satisfaction.
PRIMARY TEAM NURSING
The advantages of this approach include distinct job functions and clear division of labor among nursing staff. Additionally, there is an improved sense of security for residents and families who know who the primary caregiver is and are comforted by the consistency in caregiving. Supervisors have a clearer sense of who is responsible for meeting individual residents' needs.
One of the disadvantages that continues to exist with this approach is low satisfaction among supervisors with the responsibility of addressing personnel issues and the supervisory role required on each shift. Following the shift report, supervisors must relate changes about residents to their staff and then rely heavily on the CNAs' accurate and timely reflections of their observations to keep current on residents' conditions. This is of particular concern to nursing supervisors and facility administration because of the great difficulty of keeping the staff together, given the national evidence of high turnover among nursing assistants. In fact, according to some reviewers, it costs more to replace nursing assistants than nurses because of their higher training needs and longer phase of lower productivity (Grant, Potthoff, Ryden, & Kane, 1998).
Often, nursing assistants take positions in nursing homes because of an immediate need for employment rather than a true interest in caring for the elderly. Because of the sole financial motivation for employment, nursing assistants move from job to job. (Vance & Davidhizar, 1997). According to Banaszak-Holl and Hines (1996), often nursing assistants leave their positions within only months of being employed (Table 1).
PRIMARY TEAM NURSING
The second approach involves the combination of a licensed nurse, usually a LPN, and a CNA working together as a team to care for a larger number of residents than the primary care with nursing assistant model. The team provides all nursing care including admissions, assistance with ADLs, range of motion, administration of medications and treatments, and input into care planning for approximately 10 to 15 residents. In the rare case when the licensed member on the team is a RN, functioning as the RN Assessment Coordinator (RNAC) may be included.
PRIMARY NURSING: ALL LICENSED NURSING STAFF
There are some advantages of this model and, as indicated in Table 2, there are some areas that are seen as advantages by some, disadvantages by others. For example, the fact that less staff are needed with this model is seen as both an advantage and a disadvantage. As an advantage, this model could be seen as more cost effective because fewer benefits would be paid out with fewer people. However, as a disadvantage, there may be too few staff members to meet all resident needs and a smaller group to call on when additional staff are needed. This could also mean lack of coverage when some staff are on breaks or not enough staff are available to answer call bells.
More licensed staff creates a more professional atmosphere which enhances resident and family security and satisfaction. It offers greater opportunity for problem solving and allows earlier intervention.
PRIMARY NURSING WITH ALL LICENSED NURSING STAFF
The third approach to primary nursing uses only licensed personnel, with no CNAs. Many nurses express the desire to provide more hands-on care and are less interested in handling supervisory or management responsibilities. They feel that instead of spending time with residents they are forced to do more paperwork and perform personnel functions, such as counseling and performance evaluations for nursing assistants. In a study by Robertson et al., long-term care RNs identified the three most important "factors that satisfy" them as: recognition from patients, challenge of the work, and authority to exercise judgment for patient care. Their satisfaction is dependent on the extent to which they feel autonomous and empowered in providing care to their residents (Robertson, Herth, & Cummings, 1994).
The all licensed nursing staff model requires each licensed nurse to be fully responsible for a group of six to seven residents on day and evening shifts, with more residents per nurse during the night. This responsibility includes admission assessments, Minimum Data Set and care planning, ADLs, medications and treatments, family involvement, and overall case management.
In addition to the advantages and disadvantages of the first two primary care models, an all licensed nursing staff offers some additional opportunities and challenges (Table 3). First is the perception that an all licensed nursing staff is too costly. AU indications are that this is not the case because this model does not include additional costs normally incurred with other models. These additional costs would include ongoing recruitment efforts for nursing assistants, meeting the federal requirement for CNAs to have a minimum of 12 continuing education units per year, and the CNAs' need for supervision and direction. When examining staffing ratios and level of performance at which RNs are prepared compared to LPNs and CNAs, RNs are a greater value (Alfano, 1980). While no recent citations are available, the author's experience supports Alfano 's finding (1980).
One facility opened in December of 1995 with an all licensed staff. It was a pilot project to determine resident and staff satisfaction and financial implications with this model. The results, while early' in the life of the community, have proven to be very positive. Resident and family satisfaction has been high, and so far, the cost for operating the nursing home is lower per resident than other facilities of similar size.
Although nurses have long expressed a desire to provide handson care, when offered this opportunity several felt unsure and inadequate in the role. Some immediately recognized they were not suited for the job; others, while somewhat fearful, were excited by the opportunity. When staff of the five facilities were asked to complete a survey about the staffing models at their respective facilities, the nurses at this facility were the only ones clearly able to identify the model they were using. They also reported greater satisfaction with their degree of hands-on responsibilities.
A few of the facility's nurses continue to question the benefits of having one licensed nurse per shift as the person "in charge," but the overall impression is that with continuous open communication among the nurses, the current arrangement will prevail. One change from the initial plan is that a CNA has been added for each shift. The nurses felt an additional staff member was needed to assist the licensed primary nurses with answering bells, helping with morning or bedtime care, and other routine jobs. Therefore, when the increased resident census required the addition of another licensed nurse, the existing nurses opted to add a CNA to the shift instead. Each CNA is clearly a team member who appreciates the nurses doing all the jobs and who is equally appreciated by the rest of the nursing staff.
Regardless of the primary care model used in the long-term care facility, each of the three approaches offers quality care improvement and greater consistency for residents at reduced costs. Of the three, an all licensed nursing staff model could best meet the higher acuity levels of residents and the disintegrating availability of qualified nursing assistants. If nurses are unable to "sell" this model to administration, it may be helpful to pilot the concept on one unit for a period of time and compare resident, family, and staff satisfaction with that of a similar unit. Also, it is critical to compare the financial implications, including cost per resident per day and rate of staff turnover, to weigh the model's effectiveness. This small sampling of five facilities indicates the average cost per resident per day is $10 less when using either the primary team or all licensed staff models than in facilities of comparable size.
Hospitals have already passed the time when they have had to work smarter, leaner, and more efficiently. Can long-term care facilities afford not to do the same?
- Alfano, G.J. (1980). The advantages of the allRN nursing staff. In G.J. Alfano (Ed.), The all-RN nursing staff (pp. 1-11). Wakefield, MA: Nursing Resources.
- Banaszak-Holl, J., & Hines, M.A. (1996). Factors associated with nursing home staff turnover. The Gerontologist, 36(4), 512517.
- Gordon, D.L., Weisman, CS., Cassard, S.D., & Wong, R. (1995). Reorganizing hospital nursing resources: A self-managed unit model. In K. Kelly (Ed.), Health care work redesign (pp. 202-214). Thousand Oaks, CA: Sage.
- Grant, L.A., Potthoff, S.J., Ryden, M., & Kane, R.A. (1998). Staff ratios, training, and assignment in Alzheimer's special care units. Journal of Gerontological Nursing, 24(1), 9-16.
- Institute of Medicine. (1986). Improving the quality of care in nursing homes. Washington, DC: National Academy Press.
- McAiney, CA. (1998). The development of the empowered aide model. Journal of Gerontological Nursing, 24(1), 17-22.
- Nehls, D., Hansen, V., Robertson, P., & Manthey, M. (1977), Planned change: A quest for nursing autonomy. In Primary nursing: A contemporary nursing resource book. Wakefield, MA: Contemporary.
- Robertson, J.F., Herth, K.A., & Cummings, CC (1994). Long-term care: Retention of nurses. Journal of Gerontological Nursing, 20(11), 4-10.
- Teresi, J., Holmes, D., Benenson, E., Monaco, C, Barrett, V., Ramirez, M., & Koren, MJ. (1993). A primary care nursing model in long-term facilities: Evaluation of impact on affect, behavior, and socialization. The Gerontologist, 33(5), 667-674.
- Vance, A., & Davidhizar, R. (1997). Motivating the paraprofessional in longterm care. In CR. McConnell (Ed.), The health care supervisor (pp. 57-64). Frederick, MD: Aspen.
- Zander, K.S. (1977). Primary nursing won't work.. .unless the head nurse lets it. Journal of Nursing Administration, 7(8), 19-23.
- Zander, K.S. (1980). Primary nursing, development and management. Germantown, MD: Aspen Systems.
PRIMARY NURSING: CERTIFIED NURSING ASSISTANTS
PRIMARY TEAM NURSING
PRIMARY NURSING: ALL LICENSED NURSING STAFF