The following question was asked of the readers of the Journal of Gerontological Nursing:
What are your suggestions for modifying regulatory and enforcement strategies used by state and federal governments to promote quality in American nursing homes?
My first suggestion would be that the surveyors have longterm care experience. You cannot know about the problems in longterm care facilities unless you have worked in one.
I do not feel the fines related to deficiencies are going to change the care. The caregiver treatment has to be changed for care to be improved. The aides need to be treated with respect and given pay and benefits to compensate for the difficult job they have.
I have taught numerous nurse aide classes and many times I hear from these aides the nurses do not listen to them when they tell them about resident problems. They get frustrated and leave, and resident care suffers because of this.
Also, surprise visits and visits on shifts other than day shifts might be helpful to see how well staffed these facilities really are.
I also have heard from the nurses in these facilities that the Minimum Data Set form has not put them back at the bedside, which was its intended goal. It has bogged them down with more paperwork and taken them away from the bedside.
Linda C Sullivan, AASN, RN. ARNP
Kansas City Community College
Kansas City, Kansas
I am not presently practicing and not current as to present regulations. I do assist with the care of my 92-year-old mother in my home. My sister and I have taken on this responsibility in lieu of nursing home care for her. It is a big job, but it is satisfying for us to know she is being cared for by loving hands. We are fortunate to have the time, finances, and concern to do this.
Helen A. Lebel Edmons, MSN
Oak Harbor, Washington
I am in nursing education. I am the Skills Lab Coordinator of the Associate Degree in Nursing Department and a Clinical Instructor for the Vocational Nursing Education department at Tyler Junior College. My primary experience is in long-term care. I worked in a 110-bed nursing facility and I also work as an agency nurse covering a four-county area in east Texas. I left the previous facility because of the inconsistency of the government regulations and the various ways in which they were interpreted, both by the government regulators and the nursing home administration. Traveling from county to county to the different facilities, I am subjected to many different rules and regulations. What bothers me is these different rules and regulations come from the same government manual. This lack of consistency needs to be addressed because most nursing homes are owned by holding companies, many from out of state. Many times mandates from the California home office were unsuitable for facilities located in Texas.
I also feel a major change would be for the regulatory agencies, both state and federal, to require all inspectors to have worked as a nurse in a faculty at the level they are assigned to inspect. There is nothing worse than a hospital nurse inspecting a nursing home (or moving to a nursing home to work) and applying the instilled desire that "we must get these patients [not residents in their minds] well and back on their feet." Most of the terminal 92-year-olds just will not get much better. After experiencing such conditions as strokes, senility, or Alzheimer's disease, they just cannot be made to understand or cooperate in a bowel/bladder training program. The mind and body do not work that way.
Last but far from least, the pay scale as related to quality in die nursing home is pathetic Federal law should govern the level of pay for die aides in a musing home, not according to the minimum wage as currently established for other industries but in a scale directed at the least recognized and appreciated people in the health care industry. These people are the eyes, ears, noses, and hands of the nurses. Without good aides, the nurses' jobs become almost impossible.
Many times, I have been the only nurse for 50 to 65 residents. I rely heavily on my aides. Without them, I could not do my job. I have repeatedly raised a voice in staff meetings requesting any raise intended for the nursing staff be diverted to the aides. Almost every nurse in the meetings has agreed openly with me. However, the owners and administrators never have followed through with increasing the compensation for the aides.
At the facility where I worked previously, I would work the floor day after day with a short staff. The aides on duty would suffer. The shift to follow would suffer. Nursing suffered. Quality suffered. Complaints to the front office would bring only the response that there was no one to fill the slot. They would say they just could not find anyone to work and no one even applied for the opening. But, the nurses knew better.
I would encounter aides at other facilities who had tried to apply for positions at the facility but were told there were no openings. Meanwhile, the working aides became overworked, bitter, and tired. When a new aide would finally be hired and come to the floor, one of the working aides would quit to work at a fast-food restaurant for better pay cooking hamburgers. Then we were back to square one - short staffed. Perhaps quality would be better served if the administration would cease short staffing to conserve the hours worked.
I feel the minimum wage for aides in nursing homes should be aincreased to at least $8.00 per hour (based on my geographic location). There should be no loopholes for such things as home size. Most aides are paid $4.75 to $5.00 per hour now (which is minimum wage). There are no incentives. The Dietary Department could offer leftover foods to the staff rather than dumping it. Group insurance should be mandatory. Nursing homes that met these levels would have so many applications for the aide positions they could select the "cream of the crop" and retain a full staff at all times. They would not have overtime expenses. With a proper pay scale, terminations would be prompt for excessive tardiness and other infractions of the rules. Few excuses would be accepted. Patient care would be fantastic. Much could be expected of staff and much more could be demanded from staff. It would make nurses' jobs so much easier. In fact, the increase in wages may pay for itself with a decrease in resident complaints, which would result in decreased inspections and fines and eventually decreased regulation. I think this is the best regulatory and enforcement strategy.
For those who listen to the administrators and owners complain about wage increases, I refer them to the daily stock exchange quotes and the annual financial statements of these long-term care facilities. There is good money to be made in this industry. The records show it.
David W. McElwrath, Jr., LVN
Skills Lab Coordinator ADN Department
Clinical Instructor VNE Department
Tyler Junior College
My main concern is staffing in long-term care. A ratio of nurses and certified nursing assistants for patient care of 30 residents is inadequate. The state needs to study and review its acceptable ratio of care workers to residents. It is unrealistic for the heavy work load, and good health care workers are getting burned out.
Kathleen Suchinski, LPN
Olympus Health Care ofFarmington
Regulations regarding staffing should be modified. Most nursing homes are so short staffed, the people affected are the patients. The government should put a limit on the number of patients per certified nursing assistant and nurse. If a nursing home or hospital cannot provide adequate staffing, there should be a limit on the number of patients in the facility. It is a shame to continually admit residents to a nursing home when the corporation knows they cannot provide the staffing needed. It is the patients who suffer.
Brenda L Pick, MLPN
North Branch, Michigan
I am an Assistant Director of Nursing in a skilled nursing facility in Mississippi. In this state, staffing ratio for patients to certified nursing assistants is 10 to 1 (day shift), 15 to 1 (evening shift) and 20 to 1 (midnight shift), and of course, administration allows staffing only according to requirements. In my opinion, this ratio is too high. The patients suffer in the long run, resulting in increased incidence of patient injuries, pressure ulcers, and other incidents that ultimately can be considered neglect.
The state needs to reevaluate and lower the patient to certified nursing assistant ratio so skilled nursing facilities will be required to do the same. Elderly patients are the ones who suffer if the state does not.
Donna Redding RN
Assistant Director of Nursing
There should be mandatory caps on administrative salaries. It is frustrating to see someone make so much money and have little or no impact on residents' care. The money should be directed first to the certified nursing assistants. They are crucial to quality of care, and $7.00 per hour is a sad commentary on how much "quality" is expected.
Physicians should be involved in preventive medicine. Medications should be used sparingly. Often physicians will question why residents refuse to eat. Why should they want to eat? The residents usually receive so many medications they are full.
Community-based programs need to be sponsored by the state to involve youth volunteers in care centers.
Time-consuming paperwork should be eliminated; the Minimum Data Set should be enough.
Stade Russler, LPN
Subacute Park Regency
My suggestions for modifying regulatory and enforcement strategies used by state and federal governments to promote quality in United States nursing homes include:
* Increased training for provider staff on regulatory requirements and survey team procedures and expectations.
* A more collégial relationship between surveyors and facility staff. This would result in better quality care for residents, which is the goal after all.
* Timely evaluation of the Minimum Data Set, with input from facility staff and reexamination of problems affecting resident care.
* An understanding and appreciation of the fact that the reason the care is provided and regulated is the same - the residents. The goal is the same for every one - the best quality care for nursing home residents.
JoAnn Heath, BS, RN, C
Director of Nursing
Dial-a-Nurse of Fort Myers
Fort Myers, Florida
It is necessary to ensure adequate staffing is always on the floors and not just at the times the state or federal governments are expected to visit. For example, the facility may have 14 certified nursing assistants on the floor of a 100-bed nursing home if the state is there for inspection; however, only 6 to 8 are scheduled for everyday routine. Who is actually suffering? The patients.
Also, people should not be allowed on these state or federal boards who are able to notify one of their other facilities when the state or federal board will be visiting the facility.
This question was submitted by Mary Ellen Dellefield, RN, MS, former Director of Nursing, San Diego, California. Her commentary follows:
The readers who responded to this question have addressed pertinent issues related to modifying regulatory and enforcement strategies used by state and federal governments to ensure the quality of American nursing homes. Several suggested structural regulatory changes, such as increased levels of nursing staffing, increased certified nursing assistant wages, and additional training. Others suggested that regulatory processes of care, such as the Minimum Data Set, may have produced outcomes contrary to the original intentions. Finally, one could argue the reader's suggestion that caregivers be treated with greater respect is outside the realm of regulation, requiring instead commitment from managers and owners of nursing homes. Suggestions for changes in enforcement strategies included reduced emphasis on a system of fines for noncompliant facilities, promotion of greater consistency in enforcement by surveyors, and a requirement that surveyors have long-term care experience.
The inference I draw from these suggestions is that the readers believe there may be a relationship between the regulatory and enforcement strategies proposed and the quality of life and care experienced by nursing home residents. These suggestions reflect the common understanding that the central purpose of nursing home regulations and enforcement is to promote the quality of life and care.
In fact, nursing home regulations are a form of external quality control, developed in part because of the historic failure of the nursing home industry to self -regulate. The vulnerable nature of individuals requiring nursing home care is commonly cited as another major reason these consumers need the protection of the federal government to ensure their civil and legal rights are not violated (Insitute of Medicine, 1986).
The environment, in all its dimensions, is one of the core concepts of the discipline of nursing (Fawcett, 1993). Nursing home regulation and enforcement profoundly shapes the practice environment of all nursing staff who work in nursing homes. If professional nurses are to contribute effectively to policy discussions about long-term care, it is essential that the nature of nursing home regulation and enforcement, its purposes, demonstrated efficacy, and limitations be understood and examined in nursing research studies. Regulation is a necessary but insufficient way to promote quality. Nursing research provides an essential tool to better understand the relationship between nursing home regulation and enforcement and the enhancement of quality of life and care that is desired for all nursing home residents.
Fawcett, J. (1993). Analysis and evaluation of nursing theories. Philadelphia: Davis.
Institute of Medicine. (1986). Improving the quality of care in nursing homes. Washington, DC: National Academy Press.