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Long-term care nurse staffing requirements: Has OBRA really helped?
Long-Term Care Nurse Staffing Requirements: Has OBRA Really Helped? The OBRA requirements for nursing home staffing did not go far enough in protecting nurses and residents. By
THERESA
FRANCESE/MARTHA
n December 22, 1987, Congress passed the Omnibus Reconciliation Act (OBRA 87) , which included the Nursing Home Reform Act, now fondly known as "0BRA" in the nursing home world. OBRA was the result of years of investigations, hearings, studies, and reports about quality-of-care and quality-oflife problems in nursing homes. Grassroots advocacy by residents, families, consumer organizations, and ombudsmen played a major role in the development and passage of this legislation. The National Citizens Coalition for Nursing Home Reform coordinated many of these efforts, first advocating for a study by the Institute of Medicine (IOlvl) and later building on recommendations of the 10M to advocate for legislation. Consensus was sought among resident advocates, regulators, and professional and provider organizations. There is no doubt that OBRA has been a major turning point in the regulation of more than 15,000 nursing homes participating in Medicare and Medicaid. It gives legal support for good nursing, in that it requires care planning based on resident assessment; it places a new emphasis on residents' rights and quality of life and on the training/certification of nurse aides ; and it has established strong limits on the use of restraints and psychoactive drugs . The law requires that a licensed nurse be on duty at all times (8 hours a day this nurse must be an RN), and the regulations further require a full-time RN director of
O
THERESA FRANCESE, RN, C, BSN, is a graduate student at George Mason University and staff development coordinator at Birmingham Green, in Manassas, Va. MARTHA MOHLER, RN , MN , MHSA, is a senior policy analyst at The National Committee To Preserve Social Security and Medicare , in Washington, D.C. GERIATR NURS 1994;15:139-4l. Copyright ® 1994 by Mosby-Year Book, Inc. 0197-4572/94/$3,00 + 0 34/1/50406
GERIATRIC NURSING Volume 15, Number 3
MOHLER
nursing. OBRA did not go far enough, however, to correct the serious staffing inadequacies that the rOM acknowledged to be an important factor in substandard care. It did not set staffing standards that require 24-hour RN coverage and a basic number of personnel in proportion to the number of residents to be cared for. Nurses in long-term care have great responsibilities, but, in the absence of basic staffing requirements, they often work with few professionals and inadequate numbers of direct care personnel. When workloads are excessive, quality of care for residents is diminished, and staff morale is stressed and injuries occur. High turnover is endemic. Gerontological nurses must take time to become involved in the political process, pressing for requirements that will make it possible for nurses to provide good care. We should especially pay attention to requirements that ensure adequate nursing services staffing.
When workloads are excessive, quality of care for residents is diminished and staff morale is stressed. Funding and uses of funding will be key issues in this effort. Nursing is the heaviest cost factor in most nursing home operations. Almost half the expenditures for nursing home care come from public funds.1 Those who run the nursing home industry have expressed alarm at even the minimal OBRA licensed nurse requirements. Alleging too few nurses available and too little reimbursement to pay them, Paul Willging, executive director of the American Health Care Association, told the Senate Special Committee on Aging in 1988:
Francese and Mohler 139
CURRENT LAW AND A PROPOSED NURSE STAFFING STANDARD
I
Secu;;~-:nd ~edico;;-1
Notional Committee to Preserve Social Study of 1988 Staffing in 15,043 Certifie~ Nursi~:~om:_.~ Current Law (as of
A Proposed Standard
10/1/90)
RN DON (may serve as charge nurse if average occupancy of 60 residents or less) RN, 8 consecutive hours, 7 days/week RNjLPN 24 hours/day, 7 days/week Staffing: "Sufficient" staff needed to meet residents' needs.
I ,
1 Full-time RN DON
RN on duty 24 hours/day, 7 days/week In addition, in facilities af 120 beds or more: • 1 RN ADON • 1 RN director of in-service • A licensed nurse-to-resident minimum ratio of: 1:30 (days) 1:45 (evenings) 1:60 (nights) In addition, all direct care nursing personnel (RN, LPN, NA): 1:8 (days) 1:10 (evenings) 1:15 (nights)
DON, Director of nursing; ADON, assistant directorof nursing.
Indeed I can guarantee today, Mr. Chairman, that once the nursing staff requirements of OBRA are finally implemented in the early '90s, we will see massive numbers of nursing homes in this country terminating Medicare and Medicaidnot because of lack of desire, but simply because the nurses are not there. Even when the nurses are there, the nature of the medical reimbursement program does not allow sufficient reimbursement to pay the nurses' salaries.? Since professional and licensed nurses are more costly, the majority of care is delivered to residents by nurse aides, who have limited training and get little supervision. The 1986 TOM report on quality of care in nursing homes states: Nursing homes should place their highest priority on the recruitment, retention, and support of adequate numbers of professional nurses who are trained in gerontology and geriatrics to ensure an adequate number and appropriate mix of professional and nonprofessional nursing personnel to meet the needs of all types of residents in each facility. 3 Reform in the nursing home industry will require public support for adequate reimbursement and for requiring that funds be used to provide appropriate care. If better work conditions are to be achieved in this way, long-term
140 Francese and Mohler
care personnel at all levels will be able to experience the great satisfaction of working with elderly and disabled residents. Staff recruitment and retention should then become easier. Expansion of the elderly population will bring increased demands for capable nursing home staff, and nursing schools will therefore need to focus more attention on geriatrics, rehabilitation, and chronic illness care. Nurses Can Be the Agents of Change in Long-term Care Gerontological nurses working together to demonstrate the importance of adequate staffing can become the driving force for change. Who knows better than nurses what resources are needed to provide good nursing care?
Nursing schools will need to focus more attention on geriatrics, rehabilitation, and chronic illness care. We think, act, and vote as individual persons. But if enough of us speak on the same theme, it will be heard. We can gain strength to speak jointly by working through professional organizations. The American Nurses Association has advocated for quality nursing home care by promoting RN coverage around the clock, nurse aide training and certification, and opposing waivers of OBRA licensed nurse requirements. The National League for Nursing accredits schools of nursing. It has held invitational conferences on long-term care and workshops on gerontology. Its affiliate, the Community Health Accreditation Program, accredits home health agencies. The ANA Council on Gerontological Nursing has promoted standards of geriatric care and professional nurse certification. The National Gerontological Nursing Association and the National Association of Directors of Nursing Administration in Long Term Care focus on gerontological and long-term care nursing concerns. Tracking educational, legislative, and regulatory developments at state and national levels will allow all these organizations to keep members informed, to participate in state and national advisory groups informing legislators and the public of the resource needs for good care. Long-term Care Nurses as Agents of Change Long-term care nurses can influence care by taking action:
At the national level: • Join gerontological nursing specialty organizations and the American Nurses Association. Help them develop an agenda for improving long-term care, including measures to ensure improved staffing in nursing homes.
May/June 1994 GERIATRIC NURSING
• W rite your sena tors , congressmen, and state legislators, asking them to support legislation that promotes quality of care for older adults and the disabled . • Support and vote for candidates who favor nursing's proposals for improving long-term care. At the local level: • Be act ive in sta te and local units of nursing org anizations. He lp the m draft and promote legislative proposals for improved staffing . o Learn where your elect ed officials stand on long-term care issu es. Help th em to understand the resourc e needs for good ca re. • Promote courses in geront ological nursing in the schools of nursin g. o Take continuing educ ation courses in gerontological nursing and nursing administration. • Earn a BSN or higher degree in nursing. Call the Am er ican Asso cia t ion of College s of Nu rsi ng in Wash ington , D.C., to learn about degree programs in your area.
Who knows better than nurses w hat resources are needed to
provide good nursing care? In your fa cilities: • Help residents and families participate in plann ing and evaluation of care. • Promote profes sional nursing. Work to have a voice in all policy that affects resident care. • Document and demonstrate the resource needs for qualit y care. • Promote efficient use of resources. e Support and encourage fellow gerontological nurses. Be a role model and a mentor. e Demonstrate your expertise in gerontological nursing. Promote str ong quality assura nce. This is an exciti ng time to be a nurse. " H ealth care reform " is on the lips and minds of everyone. Nurses must ensure th at quality of care is not weakened by the emphasis on cost containment. We must set and maintain high standards for nursing care . W e must be politically aler t and act ive in secu ring the necessary resources for quality care. !ill REFERENCES
1. Healt h Care Fina ncing Admin istrat ion. Hea lth care financing review- Fall. 199 1;13(1). 2. US Sen ate Special Committee on Aging. Vanishing nurses: diminishing care . April, 1988. 3. Institute of Medic ine, Comm ittee on N ursing Home Regulation. Improving the quality of care in nursing homes. Na tion al Academy Press, 1986.
GERIAT RIC NURSI N G Volume 15, N umber 3
GERONTOLOGY NURSING FACULTY Faculty leadership position available in dynamic College of Nursing with a signature of Empowering People for Health. Long history of excellence in undergraduate and graduate education. College seeks individual with specialty in Gerontological Nursing to lead the development of a Teaching Nursing Home program. This position offers an exciting opportunity for collaboration in teaching, research, policy and practice with the University Gerontology Center and Loretto Nursing Home, the collaborating partner, dispensesafullcontinuum of service from ambulatory through skilled care. Gerontology Nursing Graduate and Undergraduate teach ing; focus on commun ity based models of care preferred. Rank and salary commensurate with educational preparation and experience. NLN accredited programs. Minimum qualifications inc lude: doctoral preparation in nurs ing or related field , Master's degree in Nursing with a focus in gerontology required; seven years experience in College or University teaching including graduate education; qualifications for senior rank appointment. Candidate must also possess: evidence of knowledge of Gerontological developmental theories and current nursing models; clinical skills in care of the special problems of aged persons and/ or programs of care for the elderly; demonstrated competence in nursing faculty practice with scholarly outcomes; demonstrated abilities in clinical administrative or policy research in nursing including potential for external funding; philosophy of nursing and gerontological nursing congruent with empowerment signature of Syracuse University College of Nursing; academic philosophy congruent with Syracuse University signature of student-centered research university; ability to work with diverse populations. Send vita and three references to: Janet Leeb, Chair, Search Committee, Syracuse University, College of Nursing, 426 Ostrom Avenue, Syracuse, NY 132443240. An Affirmative Action/Equal Opportunity Employer. Women and other traditionally underrepresented groups are encouraged to apply.
THERESA
FRANCESE/MARTHA
n December 22, 1987, Congress passed the Omnibus Reconciliation Act (OBRA 87) , which included the Nursing Home Reform Act, now fondly known as "0BRA" in the nursing home world. OBRA was the result of years of investigations, hearings, studies, and reports about quality-of-care and quality-oflife problems in nursing homes. Grassroots advocacy by residents, families, consumer organizations, and ombudsmen played a major role in the development and passage of this legislation. The National Citizens Coalition for Nursing Home Reform coordinated many of these efforts, first advocating for a study by the Institute of Medicine (IOlvl) and later building on recommendations of the 10M to advocate for legislation. Consensus was sought among resident advocates, regulators, and professional and provider organizations. There is no doubt that OBRA has been a major turning point in the regulation of more than 15,000 nursing homes participating in Medicare and Medicaid. It gives legal support for good nursing, in that it requires care planning based on resident assessment; it places a new emphasis on residents' rights and quality of life and on the training/certification of nurse aides ; and it has established strong limits on the use of restraints and psychoactive drugs . The law requires that a licensed nurse be on duty at all times (8 hours a day this nurse must be an RN), and the regulations further require a full-time RN director of
O
THERESA FRANCESE, RN, C, BSN, is a graduate student at George Mason University and staff development coordinator at Birmingham Green, in Manassas, Va. MARTHA MOHLER, RN , MN , MHSA, is a senior policy analyst at The National Committee To Preserve Social Security and Medicare , in Washington, D.C. GERIATR NURS 1994;15:139-4l. Copyright ® 1994 by Mosby-Year Book, Inc. 0197-4572/94/$3,00 + 0 34/1/50406
GERIATRIC NURSING Volume 15, Number 3
MOHLER
nursing. OBRA did not go far enough, however, to correct the serious staffing inadequacies that the rOM acknowledged to be an important factor in substandard care. It did not set staffing standards that require 24-hour RN coverage and a basic number of personnel in proportion to the number of residents to be cared for. Nurses in long-term care have great responsibilities, but, in the absence of basic staffing requirements, they often work with few professionals and inadequate numbers of direct care personnel. When workloads are excessive, quality of care for residents is diminished, and staff morale is stressed and injuries occur. High turnover is endemic. Gerontological nurses must take time to become involved in the political process, pressing for requirements that will make it possible for nurses to provide good care. We should especially pay attention to requirements that ensure adequate nursing services staffing.
When workloads are excessive, quality of care for residents is diminished and staff morale is stressed. Funding and uses of funding will be key issues in this effort. Nursing is the heaviest cost factor in most nursing home operations. Almost half the expenditures for nursing home care come from public funds.1 Those who run the nursing home industry have expressed alarm at even the minimal OBRA licensed nurse requirements. Alleging too few nurses available and too little reimbursement to pay them, Paul Willging, executive director of the American Health Care Association, told the Senate Special Committee on Aging in 1988:
Francese and Mohler 139
CURRENT LAW AND A PROPOSED NURSE STAFFING STANDARD
I
Secu;;~-:nd ~edico;;-1
Notional Committee to Preserve Social Study of 1988 Staffing in 15,043 Certifie~ Nursi~:~om:_.~ Current Law (as of
A Proposed Standard
10/1/90)
RN DON (may serve as charge nurse if average occupancy of 60 residents or less) RN, 8 consecutive hours, 7 days/week RNjLPN 24 hours/day, 7 days/week Staffing: "Sufficient" staff needed to meet residents' needs.
I ,
1 Full-time RN DON
RN on duty 24 hours/day, 7 days/week In addition, in facilities af 120 beds or more: • 1 RN ADON • 1 RN director of in-service • A licensed nurse-to-resident minimum ratio of: 1:30 (days) 1:45 (evenings) 1:60 (nights) In addition, all direct care nursing personnel (RN, LPN, NA): 1:8 (days) 1:10 (evenings) 1:15 (nights)
DON, Director of nursing; ADON, assistant directorof nursing.
Indeed I can guarantee today, Mr. Chairman, that once the nursing staff requirements of OBRA are finally implemented in the early '90s, we will see massive numbers of nursing homes in this country terminating Medicare and Medicaidnot because of lack of desire, but simply because the nurses are not there. Even when the nurses are there, the nature of the medical reimbursement program does not allow sufficient reimbursement to pay the nurses' salaries.? Since professional and licensed nurses are more costly, the majority of care is delivered to residents by nurse aides, who have limited training and get little supervision. The 1986 TOM report on quality of care in nursing homes states: Nursing homes should place their highest priority on the recruitment, retention, and support of adequate numbers of professional nurses who are trained in gerontology and geriatrics to ensure an adequate number and appropriate mix of professional and nonprofessional nursing personnel to meet the needs of all types of residents in each facility. 3 Reform in the nursing home industry will require public support for adequate reimbursement and for requiring that funds be used to provide appropriate care. If better work conditions are to be achieved in this way, long-term
140 Francese and Mohler
care personnel at all levels will be able to experience the great satisfaction of working with elderly and disabled residents. Staff recruitment and retention should then become easier. Expansion of the elderly population will bring increased demands for capable nursing home staff, and nursing schools will therefore need to focus more attention on geriatrics, rehabilitation, and chronic illness care. Nurses Can Be the Agents of Change in Long-term Care Gerontological nurses working together to demonstrate the importance of adequate staffing can become the driving force for change. Who knows better than nurses what resources are needed to provide good nursing care?
Nursing schools will need to focus more attention on geriatrics, rehabilitation, and chronic illness care. We think, act, and vote as individual persons. But if enough of us speak on the same theme, it will be heard. We can gain strength to speak jointly by working through professional organizations. The American Nurses Association has advocated for quality nursing home care by promoting RN coverage around the clock, nurse aide training and certification, and opposing waivers of OBRA licensed nurse requirements. The National League for Nursing accredits schools of nursing. It has held invitational conferences on long-term care and workshops on gerontology. Its affiliate, the Community Health Accreditation Program, accredits home health agencies. The ANA Council on Gerontological Nursing has promoted standards of geriatric care and professional nurse certification. The National Gerontological Nursing Association and the National Association of Directors of Nursing Administration in Long Term Care focus on gerontological and long-term care nursing concerns. Tracking educational, legislative, and regulatory developments at state and national levels will allow all these organizations to keep members informed, to participate in state and national advisory groups informing legislators and the public of the resource needs for good care. Long-term Care Nurses as Agents of Change Long-term care nurses can influence care by taking action:
At the national level: • Join gerontological nursing specialty organizations and the American Nurses Association. Help them develop an agenda for improving long-term care, including measures to ensure improved staffing in nursing homes.
May/June 1994 GERIATRIC NURSING
• W rite your sena tors , congressmen, and state legislators, asking them to support legislation that promotes quality of care for older adults and the disabled . • Support and vote for candidates who favor nursing's proposals for improving long-term care. At the local level: • Be act ive in sta te and local units of nursing org anizations. He lp the m draft and promote legislative proposals for improved staffing . o Learn where your elect ed officials stand on long-term care issu es. Help th em to understand the resourc e needs for good ca re. • Promote courses in geront ological nursing in the schools of nursin g. o Take continuing educ ation courses in gerontological nursing and nursing administration. • Earn a BSN or higher degree in nursing. Call the Am er ican Asso cia t ion of College s of Nu rsi ng in Wash ington , D.C., to learn about degree programs in your area.
Who knows better than nurses w hat resources are needed to
provide good nursing care? In your fa cilities: • Help residents and families participate in plann ing and evaluation of care. • Promote profes sional nursing. Work to have a voice in all policy that affects resident care. • Document and demonstrate the resource needs for qualit y care. • Promote efficient use of resources. e Support and encourage fellow gerontological nurses. Be a role model and a mentor. e Demonstrate your expertise in gerontological nursing. Promote str ong quality assura nce. This is an exciti ng time to be a nurse. " H ealth care reform " is on the lips and minds of everyone. Nurses must ensure th at quality of care is not weakened by the emphasis on cost containment. We must set and maintain high standards for nursing care . W e must be politically aler t and act ive in secu ring the necessary resources for quality care. !ill REFERENCES
1. Healt h Care Fina ncing Admin istrat ion. Hea lth care financing review- Fall. 199 1;13(1). 2. US Sen ate Special Committee on Aging. Vanishing nurses: diminishing care . April, 1988. 3. Institute of Medic ine, Comm ittee on N ursing Home Regulation. Improving the quality of care in nursing homes. Na tion al Academy Press, 1986.
GERIAT RIC NURSI N G Volume 15, N umber 3
GERONTOLOGY NURSING FACULTY Faculty leadership position available in dynamic College of Nursing with a signature of Empowering People for Health. Long history of excellence in undergraduate and graduate education. College seeks individual with specialty in Gerontological Nursing to lead the development of a Teaching Nursing Home program. This position offers an exciting opportunity for collaboration in teaching, research, policy and practice with the University Gerontology Center and Loretto Nursing Home, the collaborating partner, dispensesafullcontinuum of service from ambulatory through skilled care. Gerontology Nursing Graduate and Undergraduate teach ing; focus on commun ity based models of care preferred. Rank and salary commensurate with educational preparation and experience. NLN accredited programs. Minimum qualifications inc lude: doctoral preparation in nurs ing or related field , Master's degree in Nursing with a focus in gerontology required; seven years experience in College or University teaching including graduate education; qualifications for senior rank appointment. Candidate must also possess: evidence of knowledge of Gerontological developmental theories and current nursing models; clinical skills in care of the special problems of aged persons and/ or programs of care for the elderly; demonstrated competence in nursing faculty practice with scholarly outcomes; demonstrated abilities in clinical administrative or policy research in nursing including potential for external funding; philosophy of nursing and gerontological nursing congruent with empowerment signature of Syracuse University College of Nursing; academic philosophy congruent with Syracuse University signature of student-centered research university; ability to work with diverse populations. Send vita and three references to: Janet Leeb, Chair, Search Committee, Syracuse University, College of Nursing, 426 Ostrom Avenue, Syracuse, NY 132443240. An Affirmative Action/Equal Opportunity Employer. Women and other traditionally underrepresented groups are encouraged to apply.