- Email: [email protected]
Aide for a Day
SPECIAL ARTICLE
Aide for a Day David A. Smith, MD, CMD Abstract: The author worked for an 8-hour shift in the role of nursing assistant at a skilled nursing facility as an additional provider over and above the usual staffing. The purpose of this exercise was (1) to demonstrate to nursing assistants the respect of administration for their work, (2) to gain firsthand insights into the specific tasks they perform, and (3) to describe potential inefficiencies and barriers to providing care.
Following the shift, the author provided a written report to the administrator and the director of nursing describing the shift and making clinical and programmatic recommendations. (J Am Med Dir Assoc 2001; 2: 166–169)
There is little disagreement among long-term care administrators, directors of nursing, and physicians involved in long-term care regarding the importance of adequate numbers, training, and experience of nursing assistants (CRNAs, CNAs). Because of staffing patterns and the requirements for documentation, registered nurses and licensed vocational nurses/licensed practical nurses (LVNs/LPNs) spend much of their time behind a desk and away from direct care. Nursing assistants, then, are responsible not only for custodial care but also are expected to communicate concerns about acute or chronic changes in residents’ condition. Nursing assistants lack extensive education in nursing or geriatrics and have been provided basic education, which is abbreviated, task oriented, and narrow, in order to be certified or recertified. Some come with basic nurturing skills due to their experience as parents, homemakers, or informal caregivers of the elderly in their own families, whereas others have not had these experiences. A consensus panel has recommended the staffing standards shown in Table 1.1,2 The attorney general’s office in Texas has recommended staffing patterns similar to this. Full staffing with nursing assistants is thwarted in many areas by a strong economy and a high employment rate. However, tactics to address staffing have been discussed.3 Enhancing the training process, developing a positive work environment by nurturing job satisfaction and improving safety, and providing “perks” have been proposed.
Table 1.
METHODS With the prior approval of the administrator of a rural skilled nursing facility at which the author is medical director,
Professor of Family Medicine, Texas A&M College of Medicine, and Geriatric Consultants of Central Texas. Address correspondence to David A. Smith, MD, CMD, Geriatric Consultants of Central Texas, P.O. Box 2105, Brownwood, TX 76804.
Copyright ©2001 American Medical Directors Association 166 Smith
Keywords: nursing assistants, nursing homes, staffing
Recommended Staffing Standards*
Type of assignment
Number of FTE staff
Minimum direct care staff (RNs, LPN/LVN, CNA) 1 FTE† per 5 residents (Day) 1 FTE per 10 residents (PM) 1 FTE per 15 residents (Night) Mealtime direct care staff 1 FTE per 2–3 residents totally dependent for feeding 1 FTE per 2–4 residents partially dependent for feeding *Adapted from Harrington C, Kovner C, Mezey M, et al. Experts recommend minimum nurse staffing standards for nursing facilities in the United States. Gerontologist 2000; 40: 5–16. † FTE ⫽ full-time equivalent.
the author worked an 8-hour shift, serving as an additional staff person over and above the usual nursing assistant staffing level. The author was assigned to several residents to provide basic care and give feeding assistance to any resident needing help (without being assigned specific residents). The author was instructed to “float” to another hallway as needed. Notes were taken throughout the day to help recall observations. One CNA did not show for work or call in, leaving the facility one short (were it not for the author’s presence) until a replacement was sought. Within an hour or so, a replacement worker was found. One resident awoke with pain from arthritis, and another had nausea due to a colon cancer. The author received these complaints and went to the nursing desk to relay them to the nurse for action. Nursing staff were away from the desk doing JAMDA – July/August 2001
nursing report or other duties. The author’s choice was then to either stand idly waiting for the nurse or to return to work and hope to remember to check regularly for the nurse’s presence at the desk. Ostensibly, the nurse could then be informed of these complaints without too much delay. The author recognized that he could not do his own work and check for the nurse’s return constantly, and that also he might forget to relay these complaints. Even so, the pressure of helping people arise from bed, doing perineal care, toileting, dressing, basic hygiene/oral care/hair care, and getting residents to the dining room for breakfast took precedence. Morning routine was very labor and time intensive, more so than the rest of the day. Intake and output evaluation recording sheets were available for each resident on “I & O’s,” but these reports were not in a uniform place. It was the author’s task to record all “I & O’s.” The nursing assistant for each resident on “I & O’s” had to be sought out and interviewed. The “estimates” given by these employees were received after facial expressions and mannerisms that led the author to believe that a great deal of guesswork was involved. Glassware was used that was funnelshaped, making it difficult to estimate the volume of partially consumed fluids even if the total volume of the filled vessel were known and if these were filled uniformly. Spills and dribbling also appeared to complicate obtaining accurate data. The recording process occurred long after the meal was over, after residents received necessary hygiene, and so forth, and were returned to their rooms or to social areas. The delay could have affected accuracy. During meals, personal care, and bed-making, the nursing assistants were pleasant and respectful of residents, but the author did not observe any instances of true socialization between staff and residents. No opportunity was taken to ask partially capacitated residents to assist in bed-making, tidying up the bedside, and so forth, as a partner to the nursing assistant. Social touching, handshakes, hugs, patting, or stroking were not often observed. The author, himself, felt so pressed by the volume of basic custodial care giving that it was not easy to take the opportunity for these amenities. Nursing assistants routinely offered fluids at each encounter with incapacitated residents. While holding dirty laundry or other contaminated materials and wearing rubber gloves, the author found it extremely difficult to keep residents’ doors closed for their privacy or to open doors equipped with ordinary doorknobs. There was temptation to turn the doorknob with one’s rubber glove, which would have potentially caused contamination of the knob. Nursing staff and nursing assistants worked cooperatively and cordially, but the author did not witness evidence of close friendship or other social relationships between/among staff. RESULTS The author prepared a report for the administrator and director of nursing of the facility indicating these observations and making some suggestions. SPECIAL ARTICLE
DISCUSSION Some experts contend that nursing assistant turnover is high and performance less than optimal because the position is undervalued.3 It has been suggested that developing a more positive work environment is key to empowering nursing assistants, gaining their enthusiasm, and improving quality of care. In the author’s experience, many nursing assistants are female, poor, lack higher education, and have received only the minimum required in-service education to be certified or recertified for their work. Largely ignored, when nursing assistants are shown in the spotlight of fictionalized television or cinema, they are generally cast in a very negative way. Examples include a recent episode of Kramer, and the motion pictures Look Who’s Talking and Fried Green Tomatoes. Additionally, nursing assistants are most likely to suffer physical assault in the workplace. Nursing assistants are greater than 15 times more likely to be assaulted with injury on the job than workers in any other occupation.4 According to the US Bureau of Labor Statistics, 600,000 new nursing assistants will be needed in the near future.3 This makes recruitment and retention of direct care staff of critical importance. Similarly, it would be an advantage to improve the efficiency of the current nursing assistant workforce and to improve their clinical skills. The author suggests, from his admittedly short experience as a novice nursing assistant, the following: 1. Facilities should establish a strategy for “no show, no call” situations that highlights the fact that the individuals not reporting have let their coworkers down, rather than taking punitive action. The facility might give a perk or a bonus to all nursing assistants if, collectively, there is a “no show, no call” free month (or quarter), but everyone loses it if only one individual breaks the perfect record. 2. A spindle, blackboard, or clipboard should be placed at the nursing station in a secure location to ensure confidentiality, allowing a nursing assistant to communicate efficiently with the nurse who might not be at the desk at all times. In this way the nursing assistant may continue with necessary work, and not delay or forget to impart communications. On return to the desk, the nurse would simply check this message spot each time. 3. Nursing assistants should be encouraged and verbally rewarded for bringing concerns about a particular resident to the attention of the nursing staff, and thereby to the attending physician or medical director. Excellence in attending to resident needs of this type should be noted on job performance evaluations. This is not to say that direct care staff should be required to do nursing physical assessment, but they are in a position to see obvious changes in the residents’ condition, and hear concerns from family (or the resident’s roommate) or physical complaints from the resident.5 To assist in this task, it may be helpful to have a nursing assistant assigned to provide special attention and awareness each to a select group of residents. Although their work Smith 167
4.
5.
6.
7.
assignment might include providing custodial care, feeding, and so forth, to a larger number of residents, they would be on a “buddy system” for one or more residents to really get to know that individual. The nursing assistant with special awareness of a particular resident should be invited to the interdisciplinary care plan meeting to give input and make suggestions. This empowers the nursing assistant but also implies that they function at a higher level then is suggested by the classic job description. In the author’s experience, the practical input that can come from a hands-on caregiver is invaluable. Frequently a dialogue will take place between the physician and the interdisciplinary team, with the nursing assistant providing an exact description of a behavior problem, the nuances of a symptom, or the habits and preference of an elder. Direct care staff may also be involved in some facility committee work. Nursing assistants should be trained and guidelines provided for their interaction with family members of the residents for whom they provide care. Although a plethora of problems are possible, developing a positive interpersonal relationship between the direct care giving staff and a family may be one of the best risk management tools available to us. People generally do not litigate against others whom they understand, with whom they sympathize, or toward whom they have positive feelings. Even when mistakes are made, these interpersonal dynamics encourage dialogue or set the stage for forgiveness rather than persistent anger or the desire for retaliation or punishment. The facility might consider designating an experienced and capable nursing assistant as a “nursing assistant coordinator,” through whom communications to the direct care staff from administration and nursing and requests or communications from the direct care staff to administration and nursing might be channeled. This individual might receive the work assignments from nursing and assist in prioritizing workloads. Although this creates yet another rung in nursing administration, it gives all nursing assistants something to which they may aspire. The nursing assistant job is no longer a “dead-end street.” In some systems this technique might backfire and create animosity between nursing assistants, so the culture of the facility should be considered before implementing this suggestion. Alternative methods to avoid the dead-end nature of the nursing assistant position are to promote high-performing individual nursing assistants into restorative nursing or to encourage them on to further nursing education and a higher degree. Nursing assistants should be encouraged and rewarded for socializing appropriately with residents. They should be made aware of the opportunity to ask partially capacitated residents to assist them in bed-making, straightening the bedroom area, or setting a table. This is best done along with goals and interventions included in the treatment plan and, of course, should
168 Smith
8.
9.
10.
11.
not be thrust upon residents who will not enjoy this interaction or activity. Most of our residents are women, however, and to share this work with another woman often is a pleasing social activity, leading to a sense of well-being, usefulness, and mutual caring. The interaction blurs the boundaries between staff and residents in a positive way, making the facility feel more homelike. Doorknobs should be replaced with lever action knobs. These are more homelike then press-bars but are much easier to open with one’s elbow or hip to avoiding contaminating the doorknob with soiled rubber gloves. This would allow the nursing assistant to exit a room with dirty laundry or other contaminated materials and to return to continue their tasks without a glove change and also without leaving the door wide open in disrespect of the residents’ privacy. Intake and output evaluation and recording should not be assigned to a single nursing assistant, but should be a task assigned to each nursing assistant who has responsibility for an individual requiring this monitoring. Glassware should be chosen to facilitate accurate “estimates.” Nursing assistants should be trained to subtract spills and drooling and unconsumed amounts from the intake and output evaluation. Immediately on completing the meal or after provision of fluids at other times of the day, the nursing assistant should chart the amount taken. Every effort should be made to create uniformity in the process and make it user-friendly. If the nursing assistants have consistent assignments to certain residents, record an adequate intake and output, and yet the resident develops dehydration, it should be a fairly simple matter to determine that a particular nursing assistant lacks skill or motivation in this important task and needs additional training and encouragement. Our current mode of delivery of care makes assignment of responsibility for poor care impossible and correction not targeted to the cause. Administration may need to consider novel strategies to improve job satisfaction and retain good direct care staff. These might include alternative work schedules, single task nursing assistants if the law will eventually allow this,6 and “hospitality aides” to provide menial, nondirect care chores. Other strategies for consideration are employee assistance programs, and child care, or creating an intergenerational opportunity in the nursing home by allowing children of staff to be in the facility. Failure of the nursing assistant to show for work with or without calling, short-cutting care giving, documenting care giving that was not actually performed (such as turning and toileting) are possible. Probably the best remedy for these situations due to lack of investment or “ownership” in the job is the development of workgroup cohesion. When coworkers at the same level of employment or throughout the hierarchy of employment share friendships, respect, and mutual concern, these transgressions are perceived not so much as “getting away with something on the organization” but as JAMDA – July/August 2001
“letting your coworkers down.” These social relationships also set the stage for a collective pride in the institution and in the care that the institution provides. Workgroup cohesion is partly developed through leadership, and largely by the administration creating social opportunities among coworkers. On-the-job friendliness, respect, and even frivolity are to be encouraged, the latter within limits that do not detract from the mission of the institution. The facility may encourage or sponsor community sports teams, bowling teams, collective birthday parties once a month (for residents and staff), and so forth. These activities seem a long way removed from the institutional mission of the long-term care facility but, in the author’s experience, those facilities offering the highest quality of care have this kind of culture. CONCLUSION The nursing assistant is the backbone, both literally and figuratively, of the skilled nursing facility. Quality care depends upon their availability, training, experience, and motivation. These individuals are undervalued in our society and even
SPECIAL ARTICLE
within our industry. Much remains to be done to im-prove the quality of long-term care by empowering, educating, and increasing the numbers of nursing assistants. So many times I have heard a family member state to a nursing assistant, “I couldn’t do what you do.” The author could, but only for one day. REFERENCES 1. Harrington C, Kovner C, Mezey M, et al. Experts recommend minimum nurse staffing standards for nursing facilities in the United States. Gerontologist 2000;40:5–16. 2. Blankenheim TA. Entitled panel recommends staffing standards for nursing homes: Experts say creative solutions could outsmart labor shortage in effort to meet minimum staffing standards. McKnight’s Long Term Care News. August 2000;21:3–19. 3. Goodman A. Combating CNA turnover: The time is now. Caring For The Ages. April 2000;1:1–12. 4. Blackenheim TA. Assaults on caregivers cost healthcare industry millions each year. McKnight’s Long Term Care News. August 2000;21:15–18. 5. Boockvar K, Brodie HD, Lachs M. Nursing assistants detect behavior changes in nursing home residents that precede acute illness: Development and validation of an illness warning instrument. J Am Geriatr Soc 2000;48:1086 –1091. 6. Guagliardo J. House bill lets aides help nursing staff. McKnight’s Long Term Care News. June 2000;21:1.
Smith 169
Aide for a Day David A. Smith, MD, CMD Abstract: The author worked for an 8-hour shift in the role of nursing assistant at a skilled nursing facility as an additional provider over and above the usual staffing. The purpose of this exercise was (1) to demonstrate to nursing assistants the respect of administration for their work, (2) to gain firsthand insights into the specific tasks they perform, and (3) to describe potential inefficiencies and barriers to providing care.
Following the shift, the author provided a written report to the administrator and the director of nursing describing the shift and making clinical and programmatic recommendations. (J Am Med Dir Assoc 2001; 2: 166–169)
There is little disagreement among long-term care administrators, directors of nursing, and physicians involved in long-term care regarding the importance of adequate numbers, training, and experience of nursing assistants (CRNAs, CNAs). Because of staffing patterns and the requirements for documentation, registered nurses and licensed vocational nurses/licensed practical nurses (LVNs/LPNs) spend much of their time behind a desk and away from direct care. Nursing assistants, then, are responsible not only for custodial care but also are expected to communicate concerns about acute or chronic changes in residents’ condition. Nursing assistants lack extensive education in nursing or geriatrics and have been provided basic education, which is abbreviated, task oriented, and narrow, in order to be certified or recertified. Some come with basic nurturing skills due to their experience as parents, homemakers, or informal caregivers of the elderly in their own families, whereas others have not had these experiences. A consensus panel has recommended the staffing standards shown in Table 1.1,2 The attorney general’s office in Texas has recommended staffing patterns similar to this. Full staffing with nursing assistants is thwarted in many areas by a strong economy and a high employment rate. However, tactics to address staffing have been discussed.3 Enhancing the training process, developing a positive work environment by nurturing job satisfaction and improving safety, and providing “perks” have been proposed.
Table 1.
METHODS With the prior approval of the administrator of a rural skilled nursing facility at which the author is medical director,
Professor of Family Medicine, Texas A&M College of Medicine, and Geriatric Consultants of Central Texas. Address correspondence to David A. Smith, MD, CMD, Geriatric Consultants of Central Texas, P.O. Box 2105, Brownwood, TX 76804.
Copyright ©2001 American Medical Directors Association 166 Smith
Keywords: nursing assistants, nursing homes, staffing
Recommended Staffing Standards*
Type of assignment
Number of FTE staff
Minimum direct care staff (RNs, LPN/LVN, CNA) 1 FTE† per 5 residents (Day) 1 FTE per 10 residents (PM) 1 FTE per 15 residents (Night) Mealtime direct care staff 1 FTE per 2–3 residents totally dependent for feeding 1 FTE per 2–4 residents partially dependent for feeding *Adapted from Harrington C, Kovner C, Mezey M, et al. Experts recommend minimum nurse staffing standards for nursing facilities in the United States. Gerontologist 2000; 40: 5–16. † FTE ⫽ full-time equivalent.
the author worked an 8-hour shift, serving as an additional staff person over and above the usual nursing assistant staffing level. The author was assigned to several residents to provide basic care and give feeding assistance to any resident needing help (without being assigned specific residents). The author was instructed to “float” to another hallway as needed. Notes were taken throughout the day to help recall observations. One CNA did not show for work or call in, leaving the facility one short (were it not for the author’s presence) until a replacement was sought. Within an hour or so, a replacement worker was found. One resident awoke with pain from arthritis, and another had nausea due to a colon cancer. The author received these complaints and went to the nursing desk to relay them to the nurse for action. Nursing staff were away from the desk doing JAMDA – July/August 2001
nursing report or other duties. The author’s choice was then to either stand idly waiting for the nurse or to return to work and hope to remember to check regularly for the nurse’s presence at the desk. Ostensibly, the nurse could then be informed of these complaints without too much delay. The author recognized that he could not do his own work and check for the nurse’s return constantly, and that also he might forget to relay these complaints. Even so, the pressure of helping people arise from bed, doing perineal care, toileting, dressing, basic hygiene/oral care/hair care, and getting residents to the dining room for breakfast took precedence. Morning routine was very labor and time intensive, more so than the rest of the day. Intake and output evaluation recording sheets were available for each resident on “I & O’s,” but these reports were not in a uniform place. It was the author’s task to record all “I & O’s.” The nursing assistant for each resident on “I & O’s” had to be sought out and interviewed. The “estimates” given by these employees were received after facial expressions and mannerisms that led the author to believe that a great deal of guesswork was involved. Glassware was used that was funnelshaped, making it difficult to estimate the volume of partially consumed fluids even if the total volume of the filled vessel were known and if these were filled uniformly. Spills and dribbling also appeared to complicate obtaining accurate data. The recording process occurred long after the meal was over, after residents received necessary hygiene, and so forth, and were returned to their rooms or to social areas. The delay could have affected accuracy. During meals, personal care, and bed-making, the nursing assistants were pleasant and respectful of residents, but the author did not observe any instances of true socialization between staff and residents. No opportunity was taken to ask partially capacitated residents to assist in bed-making, tidying up the bedside, and so forth, as a partner to the nursing assistant. Social touching, handshakes, hugs, patting, or stroking were not often observed. The author, himself, felt so pressed by the volume of basic custodial care giving that it was not easy to take the opportunity for these amenities. Nursing assistants routinely offered fluids at each encounter with incapacitated residents. While holding dirty laundry or other contaminated materials and wearing rubber gloves, the author found it extremely difficult to keep residents’ doors closed for their privacy or to open doors equipped with ordinary doorknobs. There was temptation to turn the doorknob with one’s rubber glove, which would have potentially caused contamination of the knob. Nursing staff and nursing assistants worked cooperatively and cordially, but the author did not witness evidence of close friendship or other social relationships between/among staff. RESULTS The author prepared a report for the administrator and director of nursing of the facility indicating these observations and making some suggestions. SPECIAL ARTICLE
DISCUSSION Some experts contend that nursing assistant turnover is high and performance less than optimal because the position is undervalued.3 It has been suggested that developing a more positive work environment is key to empowering nursing assistants, gaining their enthusiasm, and improving quality of care. In the author’s experience, many nursing assistants are female, poor, lack higher education, and have received only the minimum required in-service education to be certified or recertified for their work. Largely ignored, when nursing assistants are shown in the spotlight of fictionalized television or cinema, they are generally cast in a very negative way. Examples include a recent episode of Kramer, and the motion pictures Look Who’s Talking and Fried Green Tomatoes. Additionally, nursing assistants are most likely to suffer physical assault in the workplace. Nursing assistants are greater than 15 times more likely to be assaulted with injury on the job than workers in any other occupation.4 According to the US Bureau of Labor Statistics, 600,000 new nursing assistants will be needed in the near future.3 This makes recruitment and retention of direct care staff of critical importance. Similarly, it would be an advantage to improve the efficiency of the current nursing assistant workforce and to improve their clinical skills. The author suggests, from his admittedly short experience as a novice nursing assistant, the following: 1. Facilities should establish a strategy for “no show, no call” situations that highlights the fact that the individuals not reporting have let their coworkers down, rather than taking punitive action. The facility might give a perk or a bonus to all nursing assistants if, collectively, there is a “no show, no call” free month (or quarter), but everyone loses it if only one individual breaks the perfect record. 2. A spindle, blackboard, or clipboard should be placed at the nursing station in a secure location to ensure confidentiality, allowing a nursing assistant to communicate efficiently with the nurse who might not be at the desk at all times. In this way the nursing assistant may continue with necessary work, and not delay or forget to impart communications. On return to the desk, the nurse would simply check this message spot each time. 3. Nursing assistants should be encouraged and verbally rewarded for bringing concerns about a particular resident to the attention of the nursing staff, and thereby to the attending physician or medical director. Excellence in attending to resident needs of this type should be noted on job performance evaluations. This is not to say that direct care staff should be required to do nursing physical assessment, but they are in a position to see obvious changes in the residents’ condition, and hear concerns from family (or the resident’s roommate) or physical complaints from the resident.5 To assist in this task, it may be helpful to have a nursing assistant assigned to provide special attention and awareness each to a select group of residents. Although their work Smith 167
4.
5.
6.
7.
assignment might include providing custodial care, feeding, and so forth, to a larger number of residents, they would be on a “buddy system” for one or more residents to really get to know that individual. The nursing assistant with special awareness of a particular resident should be invited to the interdisciplinary care plan meeting to give input and make suggestions. This empowers the nursing assistant but also implies that they function at a higher level then is suggested by the classic job description. In the author’s experience, the practical input that can come from a hands-on caregiver is invaluable. Frequently a dialogue will take place between the physician and the interdisciplinary team, with the nursing assistant providing an exact description of a behavior problem, the nuances of a symptom, or the habits and preference of an elder. Direct care staff may also be involved in some facility committee work. Nursing assistants should be trained and guidelines provided for their interaction with family members of the residents for whom they provide care. Although a plethora of problems are possible, developing a positive interpersonal relationship between the direct care giving staff and a family may be one of the best risk management tools available to us. People generally do not litigate against others whom they understand, with whom they sympathize, or toward whom they have positive feelings. Even when mistakes are made, these interpersonal dynamics encourage dialogue or set the stage for forgiveness rather than persistent anger or the desire for retaliation or punishment. The facility might consider designating an experienced and capable nursing assistant as a “nursing assistant coordinator,” through whom communications to the direct care staff from administration and nursing and requests or communications from the direct care staff to administration and nursing might be channeled. This individual might receive the work assignments from nursing and assist in prioritizing workloads. Although this creates yet another rung in nursing administration, it gives all nursing assistants something to which they may aspire. The nursing assistant job is no longer a “dead-end street.” In some systems this technique might backfire and create animosity between nursing assistants, so the culture of the facility should be considered before implementing this suggestion. Alternative methods to avoid the dead-end nature of the nursing assistant position are to promote high-performing individual nursing assistants into restorative nursing or to encourage them on to further nursing education and a higher degree. Nursing assistants should be encouraged and rewarded for socializing appropriately with residents. They should be made aware of the opportunity to ask partially capacitated residents to assist them in bed-making, straightening the bedroom area, or setting a table. This is best done along with goals and interventions included in the treatment plan and, of course, should
168 Smith
8.
9.
10.
11.
not be thrust upon residents who will not enjoy this interaction or activity. Most of our residents are women, however, and to share this work with another woman often is a pleasing social activity, leading to a sense of well-being, usefulness, and mutual caring. The interaction blurs the boundaries between staff and residents in a positive way, making the facility feel more homelike. Doorknobs should be replaced with lever action knobs. These are more homelike then press-bars but are much easier to open with one’s elbow or hip to avoiding contaminating the doorknob with soiled rubber gloves. This would allow the nursing assistant to exit a room with dirty laundry or other contaminated materials and to return to continue their tasks without a glove change and also without leaving the door wide open in disrespect of the residents’ privacy. Intake and output evaluation and recording should not be assigned to a single nursing assistant, but should be a task assigned to each nursing assistant who has responsibility for an individual requiring this monitoring. Glassware should be chosen to facilitate accurate “estimates.” Nursing assistants should be trained to subtract spills and drooling and unconsumed amounts from the intake and output evaluation. Immediately on completing the meal or after provision of fluids at other times of the day, the nursing assistant should chart the amount taken. Every effort should be made to create uniformity in the process and make it user-friendly. If the nursing assistants have consistent assignments to certain residents, record an adequate intake and output, and yet the resident develops dehydration, it should be a fairly simple matter to determine that a particular nursing assistant lacks skill or motivation in this important task and needs additional training and encouragement. Our current mode of delivery of care makes assignment of responsibility for poor care impossible and correction not targeted to the cause. Administration may need to consider novel strategies to improve job satisfaction and retain good direct care staff. These might include alternative work schedules, single task nursing assistants if the law will eventually allow this,6 and “hospitality aides” to provide menial, nondirect care chores. Other strategies for consideration are employee assistance programs, and child care, or creating an intergenerational opportunity in the nursing home by allowing children of staff to be in the facility. Failure of the nursing assistant to show for work with or without calling, short-cutting care giving, documenting care giving that was not actually performed (such as turning and toileting) are possible. Probably the best remedy for these situations due to lack of investment or “ownership” in the job is the development of workgroup cohesion. When coworkers at the same level of employment or throughout the hierarchy of employment share friendships, respect, and mutual concern, these transgressions are perceived not so much as “getting away with something on the organization” but as JAMDA – July/August 2001
“letting your coworkers down.” These social relationships also set the stage for a collective pride in the institution and in the care that the institution provides. Workgroup cohesion is partly developed through leadership, and largely by the administration creating social opportunities among coworkers. On-the-job friendliness, respect, and even frivolity are to be encouraged, the latter within limits that do not detract from the mission of the institution. The facility may encourage or sponsor community sports teams, bowling teams, collective birthday parties once a month (for residents and staff), and so forth. These activities seem a long way removed from the institutional mission of the long-term care facility but, in the author’s experience, those facilities offering the highest quality of care have this kind of culture. CONCLUSION The nursing assistant is the backbone, both literally and figuratively, of the skilled nursing facility. Quality care depends upon their availability, training, experience, and motivation. These individuals are undervalued in our society and even
SPECIAL ARTICLE
within our industry. Much remains to be done to im-prove the quality of long-term care by empowering, educating, and increasing the numbers of nursing assistants. So many times I have heard a family member state to a nursing assistant, “I couldn’t do what you do.” The author could, but only for one day. REFERENCES 1. Harrington C, Kovner C, Mezey M, et al. Experts recommend minimum nurse staffing standards for nursing facilities in the United States. Gerontologist 2000;40:5–16. 2. Blankenheim TA. Entitled panel recommends staffing standards for nursing homes: Experts say creative solutions could outsmart labor shortage in effort to meet minimum staffing standards. McKnight’s Long Term Care News. August 2000;21:3–19. 3. Goodman A. Combating CNA turnover: The time is now. Caring For The Ages. April 2000;1:1–12. 4. Blackenheim TA. Assaults on caregivers cost healthcare industry millions each year. McKnight’s Long Term Care News. August 2000;21:15–18. 5. Boockvar K, Brodie HD, Lachs M. Nursing assistants detect behavior changes in nursing home residents that precede acute illness: Development and validation of an illness warning instrument. J Am Geriatr Soc 2000;48:1086 –1091. 6. Guagliardo J. House bill lets aides help nursing staff. McKnight’s Long Term Care News. June 2000;21:1.
Smith 169