I think the title speaks for itself...but I'll try to elaborate.
It would be difficult to find any nurse who would argue against the notion that the status quo of doing business in SNF/ALF facilities needs a huge overhaul. That being said, what are the issues that need addressed?
Staff burnout, poor regulation, and care models that prioritize profit are a few that come to mind. If you work in one of these facilities what would you change?
IKnowYouRider - any thoughts from you? Or was this to provide some basis for a class paper/research project?
I have this idea in my head that I can't shake -- the best way to explain it is an integrated, partially self-sustained living community.
Some features include a 'town hall' area for small live music and guest speakers where residents would have preferred seating, but tickets would be sold as well. Also, a garden/farm to provide quality foods for the residents (and maybe nursing staff could log hours doing this type of work to prevent burnout and feel connected to the whole 'operation' and a residents library, which would also include recorded autobiographies of current and previous residents (like Story Corp)...the list goes on --
Currently in an FNP program after being a IMCU nurse for 8 years and have spent some time thinking about how I could actually be happy going to work, while still working in healthcare.
The purpose of the thread was to start diagnosing the problem I guess? Would love to hear any additional thoughts.
Staffing ratios are the most critical element in providing the care residents deserve. Dress it up any way you want to, but it takes time to provide good care. How many times have we been trained to provide a care model that we can't deliver on due to staffing constraints?
This is fuel for burnout. We know what practices lead to the best outcomes for residents. But our daily assignment is too large to include those practices in our care. Then "the system" tells us we are to blame for not doing what we know is best for residents.
One of the biggest barriers to sane staffing is competition for admissions. As facilities pop up on every street corner, the struggle to fill beds is on.
Bells and whistles are what many consumers respond to. When facilities compete for admissions, eye candy works. More elaborate decor and available amenities than the facility down the street bring in admissions.
Beautiful buildings and special services cost money to create and to maintain. A lot of money. Where does that money come from in the business model of long-term care? It comes straight out of the staffing budget.
Personnel is the biggest cost factor in running any facility. So when a huge loan payment is due every month, where do businesses cut to remain profitable? Staffing. And staffing ratios drive the quality of long term care in a big way.
Staffing and supplies - the 2 biggest budget expenses for LTC facilities. And who uses the supplies??? Staff for the residents. But does the average employee have ANY idea of what the supplies actually cost and how it adds up when items are wasted???
Examples - nurses freq open up a sterile suture removal set to remove ONLY the scissors for some need. But then they 'leave' the set on the shelf.
Like who's going to use an opened 'cannabalized', now UNSTERILE suture set after then??? WASTE.
Nurses who fail to time & date IV tubing as per facility IV P&P (usually good for 24 hrs in most facilities). Next nurse comes along and has to open up a new IV tubing (can't guess re the date on the hanging one). WASTE. And then there are some nurses who are just too lazy to re-prime the OK hanging tubing. WASTE. And IV saline flushes without the protective cellophane wrappers just left for someone else to use??? Do I know it's still saline and it's still sterile? Can I take that chance with it? WASTE.
Extra dressings and catheters brought into a room (just to have extra 'ready PRN'). But then they get left in the room and are eventually tossed. WASTE.
I could go on. But what about CNAs?
Examples - extra linens, like pads, sheets & blankets, brought into a room and left there until someone eventually tosses them into the laundry. Am thinking about the lack of linen needed but now unavail for the next employee. And then there's the extra unnec laundry wash (esp expensive if provided by an outside commercial laundry provider). WASTE. And don't get me started about disposable pulllups/briefs/diapers being hoarded??? WASTE and UNAVAILABILITY.
Personal care items, like deodorants, toothpaste/toothbrushes, powder, nailclippers, combs, hairbrushes, SHAVING CREAM (did anyone else ever count the number of opened cans just left in the shower room?) etc that overflow pts' cabinets/drawers - just being pushed around. Too much WASTE.
So what's the answer? I believe it's just a lack of knowledge that can be fixed. But it would take work and an Admin that is very supportive. A systematic program of inservice where prices and knowing what the monthly supplies cost becomes common knowledge.
Very simple: A lack of patient ratio laws. Every day, between getting report, getting vitals, blood sugars, assessing my residents, preparing meds, giving meds, responding to call bells, charting, communicating with the doctor/family, doing scheduled treatment, and charting on the patient at the end of the shift for my 30 patient assignment, I have 15 total minutes per patient for the entire shift. Over 24 hours (3 8 hour shifts), that's only 45 minutes of nursing time per resident.
That's where the shortcuts, the missed problems with the residents, the wasted supplies, the med errors, the HUGE pressure ulcer problem these places have, all come from. If your mother is my patient, she only gets 15 minutes of my time for my entire shift (assuming there's no emergency or another resident NEEDING more time, then she gets even less).
And why does this problem exist? Because nurses don't have the balls to stand up to administration and DEMAND better staffing and scheduling. And ANYBODY in a management position who doesn't realize that this ridiculous staffing is 100% of the problem that these places have desperately needs to get out of nursing or nursing administration, because they are too useless to be working in this field. I know, I know, "but nurses keep quitting." Well, if you were limiting your nurses to only maybe 10 patients per day, they wouldn't be. But the reason that they're all leaving all the time is that nobody wants to put their license on the line because you refuse to staff. Stop taking admissions until you can get the staff to handle it, and people will stop quitting. It's not rocket surgery.
Very simple: A lack of patient ratio laws. Every day, between getting report, getting vitals, blood sugars, assessing my residents, preparing meds, giving meds, responding to call bells, charting, communicating with the doctor/family, doing scheduled treatment, and charting on the patient at the end of the shift for my 30 patient assignment, I have 15 total minutes per patient for the entire shift. Over 24 hours (3 8 hour shifts), that's only 45 minutes of nursing time per resident.
That's where the shortcuts, the missed problems with the residents, the wasted supplies, the med errors, the HUGE pressure ulcer problem these places have, all come from. If your mother is my patient, she only gets 15 minutes of my time for my entire shift (assuming there's no emergency or another resident NEEDING more time, then she gets even less).
And why does this problem exist? Because nurses don't have the balls to stand up to administration and DEMAND better staffing and scheduling. And ANYBODY in a management position who doesn't realize that this ridiculous staffing is 100% of the problem that these places have desperately needs to get out of nursing or nursing administration, because they are too useless to be working in this field. I know, I know, "but nurses keep quitting." Well, if you were limiting your nurses to only maybe 10 patients per day, they wouldn't be. But the reason that they're all leaving all the time is that nobody wants to put their license on the line because you refuse to staff. Stop taking admissions until you can get the staff to handle it, and people will stop quitting. It's not rocket surgery.
Nurses standing up to management isn't going to fix the problem. State laws dictating staffing minimums to owners is what will fix the problem.
Very simple: A lack of patient ratio laws. Every day, between getting report, getting vitals, blood sugars, assessing my residents, preparing meds, giving meds, responding to call bells, charting, communicating with the doctor/family, doing scheduled treatment, and charting on the patient at the end of the shift for my 30 patient assignment, I have 15 total minutes per patient for the entire shift. Over 24 hours (3 8 hour shifts), that's only 45 minutes of nursing time per resident.
That's where the shortcuts, the missed problems with the residents, the wasted supplies, the med errors, the HUGE pressure ulcer problem these places have, all come from. If your mother is my patient, she only gets 15 minutes of my time for my entire shift (assuming there's no emergency or another resident NEEDING more time, then she gets even less).
And why does this problem exist? Because nurses don't have the balls to stand up to administration and DEMAND better staffing and scheduling. And ANYBODY in a management position who doesn't realize that this ridiculous staffing is 100% of the problem that these places have desperately needs to get out of nursing or nursing administration, because they are too useless to be working in this field. I know, I know, "but nurses keep quitting." Well, if you were limiting your nurses to only maybe 10 patients per day, they wouldn't be. But the reason that they're all leaving all the time is that nobody wants to put their license on the line because you refuse to staff. Stop taking admissions until you can get the staff to handle it, and people will stop quitting. It's not rocket surgery.
I can't speak for every state of course but after working LTC in WI for 25 years I can say there is a legal "minimum staffing hours per resident " ratio that needs to be reached and which is required by law to be prominently posted every day. The posting must include the number of residents in the building that day and the number of RN's, LPN's and CNA's scheduled each shift. Then the total hours of all nursing staff on the schedule is posted at the bottom of the form. Figuring out daily hours and posting this form for the day was the responsibility of one of the NOC shift nurses.
Not that this helps much because guess how they get around that one? Conveniently the unit managers who rarely if ever actually perform any direct resident care are somehow included in those hours. So while in actuality there are 3, maybe 4 nurses on days only of course if census is over some magic number which seemed to change daily but seemed to be around 83-85 there were double that number when those unit managers are included.
I actually asked the DON once why those unit managers were included in nursing hours and got some BS answer like the paperwork part of the job they do is still providing resident care. OK, right.. then why don't they just do ALL the paperwork. Funny thought, that!
I can't speak for every state of course but after working LTC in WI for 25 years I can say there is a legal "minimum staffing hours per resident " ratio that needs to be reached and which is required by law to be prominently posted every day. The posting must include the number of residents in the building that day and the number of RN's, LPN's and CNA's scheduled each shift. Then the total hours of all nursing staff on the schedule is posted at the bottom of the form. Figuring out daily hours and posting this form for the day was the responsibility of one of the NOC shift nurses.
Not that this helps much because guess how they get around that one? Conveniently the unit managers who rarely if ever actually perform any direct resident care are somehow included in those hours. So while in actuality there are 3, maybe 4 nurses on days only of course if census is over some magic number which seemed to change daily but seemed to be around 83-85 there were double that number when those unit managers are included.
I actually asked the DON once why those unit managers were included in nursing hours and got some BS answer like the paperwork part of the job they do is still providing resident care. OK, right.. then why don't they just do ALL the paperwork. Funny thought, that!
That's exactly how it plays out in Indiana. Unit managers, DoN, MDS, scheduler, and anyone with a title with the right letters behind their name. Same BS answer and all. It's a scam game. States need to dictate the staffing, and make it direct care staffing
Nurses standing up to management isn't going to fix the problem. State laws dictating staffing minimums to owners is what will fix the problem.
Nurses standing up CAN fix the problem. The administrative staff that probably includes 0 nurses can't do the care on their own. These places can't run without nurses. The staff needs to get together and throw their weight around. If everyone is going to refuse to work dangerous nursing assignments, something we all technically have a legal obligation to refuse, they have no choice but to start staffing. This is why union jobs strike.
We have the power to force change, we just refuse to.
I am an MDS coordinator so, I guess, part of “management.” Even so, I have been working in LTC for a long time (as a charge nurse before I got my current job). I am lucky to work for a company that is not a publicly owned outfit (no investors demanding dividends) with an owner who lives locally and seems to value his reputation. I believe that that the for-profit model of LTC is a huge impediment to quality of care. Every dollar spent on more staff is a dollar not given to a shareholder. There are currently state standards for LTC staff (at least in my state and I think in most) but they are absurdly low. My facility does not count administrative nurses in the staffing figures, but that probably varies by state. As someone else said, quality care takes time and supplies. There are no substitutes for those things. My suggestions to improve care: standards for staffing should be tightened drastically and health care companies should be non-profit in all areas (acute, LTC and ALF.) Also Medicaid really should pay more; in most states Medicaid pays less than it costs to provide care. And, from the perspective of my own job - the previous poster with 2 MDS coordinators for 240 beds - yikes! Huge workload for those 2 unfortunates.
Nurses standing up CAN fix the problem. The administrative staff that probably includes 0 nurses can't do the care on their own. These places can't run without nurses. The staff needs to get together and throw their weight around. If everyone is going to refuse to work dangerous nursing assignments, something we all technically have a legal obligation to refuse, they have no choice but to start staffing. This is why union jobs strike.
We have the power to force change, we just refuse to.
Sounds great in theory. In reality, especially in a tight job market that's just not going to happen. Sure some nurses would be on board, but not enough to force any kind of change. Most need their job too much to risk losing it and the few that are vocal about about unionizing or finding some other way to fight back will lose their job.
The employer would have to sit up and pay attention, maybe even make some real changes only if a large majority of nurses were involved. The small number of nurses that try to get the ball rolling though are expendable.
I can tell you from experience what happens is the most vocal of the nurses that try to organize are fired, even if there's no reason management can always find one. Then the early adopters of the OK, let's organize movement are appeased with a raise big enough to shut them up for awhile plus that raise is enough to ensure that nobody else starts unionizing talk. If they do there is always somebody around senior enough to remind them what happened to the last nurses that tried and it fizzles out quick.
A trio of nurses I used to work with who must've figured they didn't need that particular job anyway did exactly that about two years ago and while they became the sacrificial lambs it did result in a $5.00/hr raise for everyone else which in an economy of stagnant wages for years was huge so while staffing sure wasn't improved everyone else at least had some benefit from their activity.
They won't fire every nurse. NOBODY is that stupid. Use it.
As a new nurse, you don't have the experience to realize that in theory, what you're saying is great, the reality doesn't match up. One LTC where I was DON did exactly fire all of the staff nurses and some CNAs. It was a tight market, they had replacements hired before showing the previous out the door. Some of them had been there 20+ years, nearing retirement. In some areas with oversaturation of nursing, its a constant merry-go-round of staff due to threats and firings
IKnowYouRider
68 Posts
I have this idea in my head that I can't shake -- the best way to explain it is an integrated, partially self-sustained living community.
Some features include a 'town hall' area for small live music and guest speakers where residents would have preferred seating, but tickets would be sold as well. Also, a garden/farm to provide quality foods for the residents (and maybe nursing staff could log hours doing this type of work to prevent burnout and feel connected to the whole 'operation' and a residents library, which would also include recorded autobiographies of current and previous residents (like Story Corp)...the list goes on --
Currently in an FNP program after being a IMCU nurse for 8 years and have spent some time thinking about how I could actually be happy going to work, while still working in healthcare.
The purpose of the thread was to start diagnosing the problem I guess? Would love to hear any additional thoughts.