The Centers for Medicare and Medicaid Services' (CMS) requirements for participation of long-term care facilities were first published in the Federal Register, the daily journal of the United States Government, on February 2, 1989 (54 Fed. Reg. 5316). According to the CMS, the consolidated Medicare and Medicaid regulations have not been systematically reviewed or updated since 1991 (56 Fed. Reg. 48826, September 26, 1991) (“Medicare and Medicaid,” 1989) despite considerable changes in nursing home services as a result of increases in case-mix, resident acuity, condition intensity, as well as a plethora of quality of care concerns (CMS, 2015).
Nurses in long-term care facilities are an essential and critically important variable linked to quality of health care, patient outcomes, patient and family satisfaction, and safety. However, the current proposed regulations of July 16, 2015, for nurse staffing (Section K, Nursing Services, 483.35) are essentially unchanged (CMS, 2015). Existing regulations require that, with certain exceptions, an RN provide services in a facility for 8 consecutive hours per day, 7 days per week; licensed practical nurses (LPNs) and sufficient staff are required to meet residents' needs 24 hours per day. The requirements to determine “sufficient” staff remain undefined by CMS. All staffing data are self-reported and, according to current data and regulations, the average hours of nursing care per resident per day for nursing homes is 3.83 hours (RN, 0.52 hours; LPN or licensed vocational nurse [LVN], 0.85 hours; aide, 2.46 hours) with an additional 0.08 hours for social workers (Harris-Kojetin, Sengupta, Park-Lee, & Valverde, 2013). Highlighting a concern with self-reported data, the 2011 Staffing Survey Report stated that 3.67 hours were the total number of hours of nursing services actually provided (American Health Care Association, 2012). Neither the average nor provided staffing hours meet CMS's own study outcome that facilities with staffing levels (i.e., LPN, RN, aide) of less than 4.1 hours per resident day for long-term residents may provide care that results in harm and jeopardy to residents (CMS, 2001; Institute for the Future of Aging Services, 2007). Robyn Grant, director of public policy and advocacy for the National Consumer Voice for Quality Long-Term Care, said, “I think most people will be both shocked and appalled that there's not an RN on duty around the clock” in long-term care facilities (Span, 2014, para. 4).
The National Consumer Voice for Quality Long-Term Care and Coalition of Geriatric Nursing Organizations (CGNO) supported 24/7 RN staffing in their responses to proposed requirements by CMS by the close of the comment period on October 14, 2015. They provided evidence refuting CMS' position that it does not have sufficient information at this time to require a specific number of staff or hours of nursing care per resident (CMS, 2015). The current rulemaking seemingly favors collection of data on what constitutes a “sufficient number of staff, an appropriate level and mix of skills, [and] a manageable workload of both teams and individuals” (CMS, 2015, p. 132). The CMS is implementing systems to collect staffing information that is auditable back to payroll data.
Given decisions made by CMS and reflected in the proposed requirements for nursing services, omissions remain regarding nurse staffing in nursing home facilities. Specifically, there are no standards for nursing home administrators, minimum nurse staffing, or inclusion of advanced practice nurses (APNs), especially nurse practitioners, or requirements for staff infrastructure to include pharmacists, social workers, and physical, recreational, and occupational therapists.
Unfortunately, the nursing home industry or nursing home residents cannot afford to wait another two decades or even 2 years for substantive reform to the consolidated Medicare and Medicaid regulations. In this second decade of the 21st century, it is clear and compelling that America's demography is becoming more multifaceted than in the past due to aging Baby Boomers and the rise in minority populations. Globalization of the nursing workforce presents opportunities and challenges. Some research has addressed issues of internationally educated RNs but less attention has been directed to other members of the health team, such as LPNs and unlicensed assistive personnel (Sherwood & Shaffer, 2014; Williams, n.d.). A majority of long-term residents are White; however, the labor force is becoming more racially and ethnically diverse (CMS, 2015; Eliopoulos, 2015; Institute of Medicine [IOM], 1996). Language and cultural differences can lead to opportunities for new meaning and understanding but also present challenges. Bally (2007) and Williams (n.d.) allude to exploitation and times when members of the foreign-educated nursing staff encountered racism and attitudes of detestation. The caregiving labor force as part of the nursing care team requires guidance from RNs educated and skilled in topics of cultural orientation and competence, spiritual and ethnic orientation, civility, ethics, and inclusivity. No resident in long-term care should endure 16 hours of care without RNs who possess these essential skills and knowledge. Skilled communication, trust, shared responsibility, mutual respect, and optimism are critical to building successful collegiality among professional nurses and the health care team and providing better outcomes for care recipients (Bally, 2007).
Baby Boomers have the potential to change the character and quality of long-term care just as they changed the nation's school systems and labor, housing, and stock markets, heralding bold transformations (Frey, 2008). Without pivotal action by RNs, the lay public, consumers, private sectors, and government, the future of long-term care may worsen. Adding post-acute care patients in long-term care facilities contributes to higher complexity of care, often straining the competence and compassion of staff. Further, the number of children and adolescents with severe long-term health conditions in long-term care facilities and nursing homes is expected to increase as lifespan across conditions increases (IOM, 2001). The fact that nursing homes, unlike acute care facilities, lack infrastructure and 24-hour services from RNs, as well as medical, pharmacy, dietary, transportation, radiography, and emergency staff, cannot be ignored. Consequently, there is a need to set a robust evaluative national research agenda with the many stakeholders, including professionals, consumers, and government agencies, to examine and shape the future of quality long-term care. How will the proposed rulemaking of CMS from July 16, 2015, accomplish such an agenda? The current article discusses several aspects of a needed evaluation and potential reform for long-term care facilities, particularly in relation to nurse staffing.
Responses and Policy Options
The Nursing Home Reform Act of 1987 mandated and standardized services nursing homes must provide for residents, including periodic assessments and a comprehensive care plan for each resident, as well as nursing, social, rehabilitation, pharmaceutical, and dietary services. In addition, in facilities with >120 beds, the services of a full-time social worker were also required (Omnibus Budget Reconciliation Act, 1987).
Approximately 20 years later, nursing homes continue to be faced with substantial challenges and transformations. The population of nursing homes has changed and become more clinically complex and precarious. In 2012, approximately 15,700 nursing homes provided services to more than 1 million frail older adults and others with functional limitations; approximately 50% of residents have Alzheimer's disease and other dementias and/or depression; a majority of residents need assistance in bathing, dressing, toileting, and eating; and a growing percentage of residents are 85 and older (Harris-Kojetin et al., 2013). Adding to this complexity are an increasing number of residents with mobility disability, post-acute care residents, and an increasing number of non-elderly adults with serious congenital or chronic disorders and injuries. The degrees of separation between the hospital and nursing home are being compressed. As a result, RN staffing becomes even more critical and challenging.
Compelling evidence-based research has provided more information and knowledge regarding resident safety, health outcomes, individual choice, and quality assurance and performance improvements (CMS, 2015; Eliopoulos, 2015). The presence of an RN 24/7 and increased nursing hours support the Patient Protection and Affordable Care Act's (2010) three goals: (a) increase access, (b) increase quality, and (c) decrease cost. As indicated above, CMS has developed systems to increase the accuracy and timeliness of data, which will require necessary time and money for implementation and evaluation. While awaiting CMS data to drive the next steps and rulemaking, serious consideration should be given to strong supportive “stopgap” implementation of the 1996 IOM recommendation, Nursing Staff in Hospitals and Nursing Homes: Is it Adequate?, affirming the need for and requiring the presence of at least one RN within every facility at all times (i.e., 24/7 RN coverage) (IOM, 1986, 2001). The implementation of this measure is overdue and represents a threshold for ensuring that residents of nursing homes receive quality care that will result in achieving or maintaining their highest optimal physical, mental, and psychosocial well-being as the law requires. Requiring 24/7 RN coverage is a reasonable step forward and does not abridge measures focused on competency-based staffing that may be instituted later.
Zhao and Haley (2011) and other researchers have demonstrated that higher RN staffing hours per resident day are associated with lower malpractice paid losses (Eliopoulos, 2015; Institute for the Future of Aging Services, 2007). Nursing homes with low ratios of RNs to total nursing staff also have higher hospitalization and rehospitalization rates (Eliopoulos, 2015; Thomas, Mor, Tyler, & Hyer, 2013). It has also been reported that insufficient numbers of RNs have deleterious consequences in that residents achieve poorer quality outcomes (Castle, 2001, 2008; Castle & Engeberg, 2005, 2010; Eliopoulos, 2015; Harrington, Carillo, Dowdell, Tang, & Blank, 2011; Harrington, Stephens, & Wagner, 2015; Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000; IOM, 2001; Schnelle et al., 2004). Recent reports indicate that directors of nursing in the American Association for Long-Term Care Nursing certification programs do not yet understand how to determine the hours of staffing required based on residents' needs (Eliopoulos, 2015). Nurse administrators and managers may use research resources, such as the Framework for Nurse Staffing in Long-Term Care Facilities, to analyze and evaluate staffing and guide informed decision making to address the multiple variables related to staffing and resident/patient outcomes (Mueller, 2000).
According to McConnell, Lekan, and Corazzini (2010, p. 153), “the sheer size of the gap between what we have and what we need to ensure adequate nurse staffing in long-term care is staggering.” CMS makes the case that some states, although probably less than 10, have already instituted 24/7 RN coverage in long-term care (Zhang, Unruh, Liu, & Wan, 2006). Current and recent evidence supports 24-hour RN staffing, as a synthesis of research on nurse staffing from 1991–2006 revealed that higher levels were positively associated with fewer pressure ulcers, restraints, and deficiency citations (Castle, 2008).
Another potential improvement in staffing, safety, and quality of health care in nursing homes could be realized by including APNs. APNs, both NPs and clinical nurse specialists (CNSs), usually prepared at the masters and/or doctoral levels with additional certification in care of older adults, are associated with improvements in several measures of health and behavior of residents in long-term care as well as improvements in family satisfaction (Cacchione & Shah, 2016; IOM, 1996, 2001; Martin-Misener et al., 2014). The number of NPs employed in nursing homes and other long-term care settings is small but pivotal given the dearth of time spent by physicians and medical directors in nursing homes and long-term care settings (Levine, Savino, & Siegel, 2006). NPs and CNSs are autonomous and collaborative members of the interdisciplinary team who are capable of enhancing the accessibility and quality of primary care in nursing facilities and serve as a resource to the nursing staff who are increasingly challenged by the complex needs of residents (Cacchione & Shah, 2016; Donald et al., 2013; Martin-Misener et al., 2014). The data that are available on NPs in long-term care suggest that they enhance the provision of necessary health care services to residents and prevent unnecessary hospitalizations (McAiney, 2005). McAiney (2005) reported that NPs had a significant impact on long-term care facility staff by helping increase staff confidence in recognizing signs and symptoms of potential problems and in the provision of care to residents. State action is needed to extend the scope of practice for these practitioners. Additional research needs to be conducted on this topic. It is critically important that NPs in long-term care be supported in practicing to the full extent of their education and training and be included in staffing documentation, patterns, and data collections. Practitioners and RNs hold great potential to lead change and advance health for those residing in long-term care facilities (Cacchione & Shah, 2016; IOM, 2011).
There is currently a bill in the House of Representatives that supports 24/7 RN coverage in nursing homes. The Put a Registered Nurse in the Nursing Home Act of 2015 (Span, 2014), sponsored by Congresswoman Jan Schakowsky (D-IL), was introduced in February 2015 and seeks to amend the Social Security Act to establish a minimum direct care RN staffing requirement at long-term care nursing facilities. The bill has been referred to the Committee on Ways and Means and the Committee on Energy and Commerce. The bill, which requires bipartisan and bicameral support, states:
A skilled nursing facility must use the services of at least 1 registered professional nurse to provide assessment, surveillance, and direct care to residents 24 hours a day, 7 days a week. In the preceding sentence, the term “surveillance” means the purposeful and ongoing acquisition, interpretation, and synthesis of residents' data for clinical decision making. (“Text of the put a,” 2015, Section 1819 (b)(c) of the Social Security Act)
This bill is supported by the American Nurses Association (ANA) as well as the CGNO (n.d.), which includes seven geriatric nursing organizations whose 29,000 members work with older adults wherever they receive their care. The CGNO advocates for staffing levels high enough to prevent harm and provide quality.
The following recommendations to support 24/7 RN staffing in long-term care based on evidence and policy support from leading geriatric organizations address the majority of the long-term care population inclusive of frail older adults who typically represent >60% of the nursing home population:
- Encourage Congress to pass H.R. 952, Put a Registered Nurse in the Nursing Home Act of 2015; nurses across the country should write to their elected congressional representatives and advocate for enhanced RN staffing in long-term care facilities and support of 24/7 RN coverage.
- Work with stakeholders and CMS to implement the IOM recommendation requiring the presence of at least one RN within every facility at all times.
- Work with the ANA and other advocacy groups to gain bipartisan and bicameral support for H.R. 952.
- Inform CMS about the nursing community's support of continued exploration of competency-based criteria to define what is meant by sufficient RN staffing.
- Highlight to CMS the critical evidence-based knowledge behind requiring a minimum of 4.1 hours of nursing care per resident per day for nursing homes.
- Inform CMS via nursing organizations of the importance of including APRNs in nursing home staff.
- Shape an innovative research agenda supported by health scientist administrators and federally employed scientists from the National Institute of Nursing Research in partnership with the National Institute on Aging to investigate and influence the future of quality long-term care.
The goals of the current article are three-fold: (a) 24/7 RN staffing; (b) more APRNs; and (c) an enhanced research agenda on staffing in nursing homes. Consumers and nursing have mobilized to increase the presence of RNs from 8 hours to the safety net of 24/7 RNs in America's Medicare- and Medicaid-certified nursing homes. The current authors have made the case for nursing to collaborate with consumers, the public, caregivers, regulators, and other professionals to educate Congress of the need for a minimum of 24/7 RN care in nursing homes. The introduction of Put a Registered Nurse in the Nursing Home Reform Act in 2013 and 2014 was historic. The bill must become both bipartisan and bicameral to be passed. Research strongly supports the role of APRNs in improving quality of care and life for both residents and the nursing workforce. State action is needed to extend the scope of practice for these practitioners. Finally, nurses and other nursing home researchers should build on the existing extensive research to support 24-hour RN presence in nursing homes. Action is needed now.
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