A Place for Mom: Staffing Concepts and the Role of the Nurse in Assisted Living

Second of a multi-part series on assisted living facilities and how they serve the elderly who are too frail to live at home safely, yet not ill enough for placement in custodial care. Here we examine staffing models and the different roles nurses have to play in community-based care. Specialties Geriatric Article

A Place for Mom: Staffing Concepts and the Role of the Nurse in Assisted Living

"It's a beautiful day in the neighborhood" might be the theme song in many assisted living communities, which are often organized into two or more 'neighborhoods' of 10 to 25 residents, depending on the building's layout and size. Each neighborhood has a resident assistant (RA) of some kind, either a CNA or lay caregiver, who is responsible for all of the residents in that section and assists them with ADLs, does their housekeeping and laundry, and sometimes even administers medications under the direction of a licensed nurse.

Other ALFs also have assigned RAs, plus medication assistants who pass all of the scheduled and PRN meds. One of the most controversial and hotly-debated issues in assisted living is the use of largely uneducated workers to give medications that, in some cases, can greatly harm residents if given unwisely or incorrectly. It can be argued that it takes licensed nurses two to four years to learn how to administer medications properly, yet corporations expect med aides (MAs) to be able to do it in 40 hours of training or less!

The trouble is, most companies that run ALFs do so on a shoestring. Since many charge residents hundreds, if not thousands of dollars less per month than the typical nursing facility, naturally the profit margin is going to be smaller......and nobody goes into business to barely scrape by. Thus, wages tend to be very low for the line staff, who in many cases are not required to be licensed or certified.

Unfortunately, the consumer often gets what he or she is willing to pay for, and ALF residents are no exception. Very few people want to work hard, be exposed to all sorts of bodily substances, and put up with fussy elderly people and hovercraft families who do nothing but pick and criticize.....especially for minimum wage. But the vast majority of those who do are compassionate and patient, and they do a great job for very little reward. It's when workers who lack education and understanding of human psychology are placed in a situation where they are asked to work beyond their competence that problems arise.

Here's where the nurse comes in.

An assisted living nurse, whether RN or LPN, is a little bit of everything. (For the sake of clarity, we'll call the nurse a "she".) To the powers that be, she's a huge expense (in many cases, nurses out-earn their administrators). To the staff, she's something of a school principal who is to be respected---at least on the surface---and perhaps even feared. To families, she is either a port in the storm or the one to blame when things go sideways with their Mom or Dad. But to the residents, she's a combination of healer, psychiatrist, confessor, health teacher, advocate, and boo-boo fixer extraordinaire.

The role of the nurse is another area where different states and different regulations create chaos. Some states mandate the presence of an LPN or RN in ALFs at all times of the day and night, while others permit them to employ a nurse for only a few hours a week to oversee delegated staff, who administer all of the medications including insulin and Lovenox injections, and perform treatments which may include wound dressing changes and catheter flushes.

Delegation, in the latter case, is the key. Only an RN may teach tasks of nursing care to unlicensed assistive personnel. She must also be able to identify proper candidates for delegation, supervise them at least periodically, evaluate them for continuing competence in these tasks; and if they cannot or will not perform the tasks correctly, she must rescind the delegation.

If this sounds scary, it should. Trust is a huge issue here,and not every nurse has the intestinal fortitude to place a brittle diabetic in the hands of a 22-year-old high-school dropout and allow her to give him sliding-scale insulin. But in assisted living, this happens every day.....and for the most part, with excellent results.

In the next article, we'll look at move-in criteria, where to look and what to look for when choosing an assisted living facility.

Long Term Care Columnist / Guide

I'm a Registered Nurse and writer who, in better times, has enjoyed a busy and varied career which includes stints as a Med/Surg floor nurse, a director of nursing, a nurse consultant, and an assistant administrator. And when I'm not working as a nurse, I'm writing about nursing right here at allnurses.com and putting together the chapters for a future book about---what else?---nursing.

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Specializes in retired LTC.

Viva - Your articles are very, very appropos and should somehow be mandated as required reading for nsg students and others who seek information about this subset of post-acute care and living options. The literature out in the public domain talks about 5-star accomodations and gourmet dining but that's the fluffy stuff, not the reality. Of course, fluff is prettier to see and hear for the uninformed.

I've been in our end of this industry for 20 + years and I find myself nodding to every one of your words. Kudos to you.

Specializes in LTC, assisted living, med-surg, psych.
Viva - Your articles are very, very appropos and should somehow be mandated as required reading for nsg students and others who seek information about this subset of post-acute care and living options. The literature out in the public domain talks about 5-star accomodations and gourmet dining but that's the fluffy stuff, not the reality. Of course, fluff is prettier to see and hear for the uninformed.

I've been in our end of this industry for 20 + years and I find myself nodding to every one of your words. Kudos to you.

Thank you. :bow:

What you said about the 5-star accommodations and gourmet dining is spot on! At one of the ALFs I worked in before this one, even the management was expected to wait tables in the formal dining room and go out on marketing visits.......neither of which I'd signed up for when I accepted the job offer.

It was only two short months after beginning work at that facility that I found myself in my best suit one day, serving lunch with a napkin draped over my arm, and a small but very clear voice yelled in my ear: "Is this what you went to nursing school to do!?" I didn't actually mind helping in the dining room, but I minded terribly what it stood for, and I especially minded the fact that while I was playing waitress, I wasn't getting NURSING stuff done. There were plenty of other reasons why I left that job, but that's the one that stands out the most.

Specializes in Home Care.

I keep telling myself that one of these days I'm going to sit and write an article about "senior lodges" here in Alberta, Canada.

They're sort of along the idea of an ALF, but rather than be employed by the ALF our nursing and care services are provided by homecare agencies.

The lodge where I work has around 300 residents who take meals in dining rooms. They are all expected to perform the vast majority of ADLs for themselves.

But with a shortage of LTC beds homecare goes in to assist with ADLs and meds. None of our clients need help with transfers or toileting.

I supervise minimally trained healthcare aids, I have 140 home care clients in this lodge, morning shift comprises 12 HCAs, 4 of whom pass meds.

Thankfully, the majoriety of my HCAs are terrrific.

Did I say I'm an LPN and I really like my job.

I work as an LVN alongside Med Techs in an assisted living facility and have seen or caught so many mistakes that to them were no big deal. Like forgetting to punch and pass digoxin but still signing for it, or signing for 18 units of lantus insulin and then getting busy and not administering it. Med Techs arent trained to know what they are doing or not doing.

Specializes in LTC, assisted living, med-surg, psych.

Sounds like they haven't been trained very well. That could be disastrous, to say the least.

You know, you can teach a monkey to hand out pills; what you can't teach is the rationale for doing things a certain way. People, on the other hand, have almost limitless capacity to learn, and most will learn best if they are given the whys and wherefores of what they are being asked to do. When I'm training a medication assistant, I not only show them how to pass meds and deal with paperwork, I plant little seeds of wisdom, such as giving them a simple explanation of the science behind such actions as holding digoxin for a HR

I do this all the time, even with the experienced MAs, and I have to say that most of them are like sponges---they soak up every drop of knowledge they can get. The ones who don't care about learning more rarely last, because the competition to get into the med room is tough and it doesn't take long for the established crew to let me know who isn't catching on.

Is there any way you can help train your MAs? Two or three shifts shadowing another MA is the usual method of training in ALFs, but it's not adequate and needs to be scrapped.

I'm new to the this site I've been reading the post every now and then. I came across this one and I had to post a reply because I thought I was the ONLY Viva in the world! LOL! Hello name mate! Two great divas with a great name ! Enjoy your week!

I wish you were at my facility training the techs, I am new to the ALF and as you said trying to explain rationales at times that it seems things slip or dont happen and why they cant just skip em. The ALF charge LVN spends the entire day in an office away from those passing meds and never sees what goes on.

Specializes in acute, critical, home, assisted, MRDD.

This is an area of nursing that is so dear to me. After years in acute and critical care I had to modify my activity for health and physical reasons. Begrudgingly I began nursing in an ALF. I have to admit, I wasn't very good at the first one. I guess I really didn't understand the scope of what was needed from me. But the years and experience educated me well to this area. I guess I had been so accustomed to working with other licensed professionals, I didn't know what to expect from 'caregivers' and 'med aides'.

Anyway, initially [and continually] I found that there was little direction or training for ALF nurses. I guess they expect that if you have acute care nursing skills - you should be able to manage an ALF. What bothered me so much was that my layman staff was given so little training - - and even less respect for the jobs they do. Luckily, I love to teach nearly as much as I love hands on nursing. Over the years I developed a med aide training manual and all sorts of other training, education, delegations, forms, etc. Anytime one of my staff came up with an inquiry about a particular diagnosis that I already hadn't addressed I would make up more educational sheets ~ not required reading but available for their interest. Even though the corporation I worked for gave little time to training med aids I felt it was of ultimate importance. Beyond the practicle, I wanted to feel assured that this new med aide was empathetic and held themselves as 'patient advocate'. So had the primary good nurse qualities.

ALF is a whole different arena of nursing. It is not well paid or much respected. But it is essential and will only be needing more qualified nurses as my 'baby boomer' generation continues to age and become needy.

Now that I am retired (unwillingly !) I can say things that I couldn't before. My gripe is the focus of these corporations is strictly profitability. Sure I want ends to meet and everyone to have their profit. But healthcare is a service - a hands on caring for individuals. If the profit out-ranks the care, then it will eventually either become cruel or fold.

Maybe someone here can direct me in a way that I can provide some of the educational resources I have put together for other nurses and/or facilities. Sure, I would like to make some money at it, but the important thing is to be a resource.