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Maximizing RN potential in a long-term-care setting
MAXIMIZING RN POTENTIAL in a
Long-Term-CareSetting Even with limited RN staffing, professional supervision and planning of care is possible. JOANNE PATTERSON All nursing home care should be directly supervised and planned by a professional nurse. This belief was the basis for the development of what we called "district nursing" at Bergen Pines County Hospital, after the long-term-care division at this facility became the teaching nursing home for Rutgers University College of Nursing.* *This formal affiliation was jointly supported by the Robert Wood Johnson Foundation and the American Academy of Nursing. Each site organized its program to meet their needs while meeting the objectives of the project. Joanne Patterson, RN, MS, was clinical director and member of the faculty of Rutgers University/Bergen Pines Hospital Teaching Nursing Home Project. She is now a member of the faculty of Rutgers University College of Nursing, Newark, NJ.
142 Geriatric Nursing May/June 1987
The 1~2nursing home units at Bergen Pines were divided into districts with approximately 15 residents in each. A patient classification system was used to estimate residents' nursing needs and to balance the assignment of residents and nursing personnel to the districts. Because of economic constraints, the number of registered nurses within our division had peaked at a level which allowed for one registered nurse per district; this RN was named district leader and assumed 24-hour-a-day, 7-daya-week accountability for the clinical management of all residents within his or her district. Within a short time, district nursing resulted in changes in three areas: performance of registered nurses; roles of the head nurse and clinical director; and attitudes of undergraduate nursing students assigned to the long-term-care division for clinical experience. Performance of RNs Each district leader works from 7:00 AM tO 3:30 PM, the time when
most resident activity, interdisciplinary interaction, and decision making takes place. Nursing statfon other shifts implement the district leaders' care plan, monitor residents' responses to these plans, transmit this information to their district leader, and propose modifications when necessary. As district leaders, registered nurses in the long-term-care division are responsible for resident care, management, advocacy, resident and family education, quality assurance, and professional development. This differs from the task-oriented functional role of assigning nursing personnel in which RNs were rotated through a series of selected assignments such as administering medications and treatments, bedside care, and unit administrationm"the desk"--without the benefit of continuity of assignment or the opportunity to be accountable for the total nursing care of any particular resident. Resident care responsibilities are not only more comprehensive but
have been expanded to include knowing the resident classification system and serving as a multidisciplinary team member. District leaders are now also accountable for an array of management functions, the most important of which are assigning and directing resident care, communicating pertinent information to district members, and participating in the evaluation of ancillary personnel assigned to them. This new position also requires that district leaders assume the role of resident advocate, previously considered a function of the head nurse. With the responsibilities of resident and family education comes the accountability for the quality of the education the district leaders provide (for example, its timeliness and relevance). Rather than head nurses, district leaders initiate family meetings and see the family more as "clients" rather than as "adversaries." In addition, district leaders constitute most of the membership on the Long-Term-Care Quality Assurance Committee, once a function of the head nurse, and are responsible for monitoring and evaluating standards of care. Interdisciplinary communication has greatly improved since district leaders now participate in the regularly scheduled interdisciplinary care-planning conferences. Because other disciplines deal primarily with district leaders, greater continuity, accountability, and specificity of care has resulted. The area of professional development has been the least altered. RN responsibilities remain the same except that in accordance with the status of Bergen Pines as a teaching nursing home, the registered nurse's responsibility for teaching both staff and students is specified in the job description. In units where the district model has been in place the longest (about three and a half years), the nurses are able to make decisions and move on their own initiative, more fully understanding the meaning of autonomous practice. They have become creative and personalized in their care of residents and, where possible, envision for them more than just maintenance and support.
The area most difficult for the majority of district leaders seems to be teaching and guiding the nursing attendants assigned to their districts. Where ancillary workers are noncompliant or where constructive criticism has to be shared, a reticence to get involved persists. Because managerial functions have been the most difficult for district leaders, an educational program was designed to teach the knowledge
Rutgers" faculty. Thus, clinical directors had to divide their efforts between service agency responsibilities and clinical teaching and other duties associated with the faculty role. In addition, at the start of the program clinical directors also were to assume the role of primary health care provider for the 120 residents on their assigned units. In view of time constraints, it soon became evident they could not perform as initially
Students began to see the opportunities for autonomous, challenging, and satisfying practice: here they could really make a difference.
and skills necessary to evaluate sub- projected. Instead, the clinical direcordinates, deal with conflict resolu- tors proposed the idea of delegating tion, delegate work, and be assertive some of these primary care duties to in exercising one's rights and respon- district leaders. sibilities. Since the district leaders are in intiThis "Leadership and Manage- mate association with a limited numment Series for District Leaders" ber of residents, the clinical directors consisted of 3 three-hour workshops, believed that stabilized chronic illfocusing on managerial functions ness could be monitored and disease (planning, directing, controlling, and prevention and health promotion coordinating); leadership styles; could be well Served within their women in leadership roles; group dy- scope of practice as registered nurses. namics; effective communication; The clinical skills essential to this reduction of situational stress (con- role are best taught formally through flict resolution, time management, a physical assessment course proprioritizing, problem solving, and vided by the Rutgers College of Nurspeer support); change theory; partici- ing Continuing Education Program patory management; and perform- and informally through bedside ance appraisal. It was later desig- teaching provided by clinical direcnated as mandatory for all district tors. The clinical directors schedule leaders and is now included in the their time according to the needs of standard orientation given to all new their assigned units. registered nurses. This turn of events influenced the design of the clinical directors' role Roles of Clinical Director which includes: formal education of and Head Nurse students; resident care management: District nursing and the subse- developing, enforcing, and evaluatquent evolution of registered nurse ing the standard of nursing care and responsibilities at Bergen Pines directing the nursing management of changed the roles of clinical director complex clinical situations; human and head nurse. At the outset of the resource management: developing affiliation between Bergen Pines and and evaluating nursing staff; unit Rutgers, masters' prepared clinicians management: assisting in the develwere designated as clinical directors opment of unit budgets and in the deand held authority for the clinical velopment, application, and promoprogram in assigned geographic areas tion of quality assurance and risk of the division; they also served as management programs; scholarly ac-
Geriatric Nursing May/June 1987 143
Another district leader successfultrict. Two students constructed a customized chair for a resident, which ly intervened with an apathetic, soprovided him with a means of here- cially withdrawn, elderly resident tofore unavailable mobility; one stu- who refused to eat and was steadily dent developed an oral hygiene pro- losing weight. After seven months, gram for residents in her district; and this resident gained 13 lbs, goes out three students reorganized the socially on trips sponsored by R e nurse's desk on the unit to promote creation Therapy, and has become a greater efficiency and easier retrieval source ofcomfort and support to others on the unit. of information. Another district leader eliminated Essentially, we found that students tire quickly of the task-oriented func- an elderly polio victim's dependence tions of the registered nurse (that is on routine (every four hours) Dardistributing medications, doing yon through individualized care. treatments, and taking off orders), This resident rarely requests even but they are challenged by personnel Tylenol, is pain free, more alert, and management, the primary health engages in social activities and relacare role, and these improvement tionships. Still another district leader sucprojects. They seem to see this cliniAttitudes of Students cal experience as their opportunity to cessfully intervened to facilitate an Perhaps the most interesting and make a difference. elderly resident's adjustment to her significant outcome to emerge after new colostomy. This resident's iniConclusion tial reaction of denial and fear has the advent of a program such as disWhat is obviously missing in this now changed to some degree of actrict nursing is the gradual change in attitudes of advanced undergraduate account of changes with the devel- ceptance (that is, she handles the nursing students toward placement opment of district nursing is an ac- equipment, discusses her care, tells in the long-term-care division for count of spectacular improvements staff when colostomy care is needed, clinical experience. In past years, un- in outcomes of care. Divisionwide and participates socially to a much dergraduate students perceived long- we cannot say that there have been greater degree). term care as an inappropriate clinical sweeping changes in the resident Small victories like these are taking place all over the long-term-care division at Bergen Pines. The best parts of a phenomenon such as this are that staffcan identify the changes Given the opportunity, support, and guidance and realize that they have been instrumental in bringing them about. to use all their skills, RNs can become the most Through such vehicles as the "Long important resource in the nursing home setting. Term Care Nurse Forum" and "Bright Ideas" conference, staff are able to share their experiences with colleagues. It is our belief that if our efforts at setting for their final semester of population: the discharge rate is still study in nursing theory, manage- the same; the self-care population is upgrading and expanding the role of ment, change theory, and profession- still small; and the majority of the registered nurses within long-term al socialization. With district leaders residents still suffer from confusion, care accomplished one crucial thing, in place, students enthusiastically ac- impaired mobility, incontinence, it was to empower them. Once given the opportunity, support, and guidcepted clinical placement in the divi- and the like. sion. Why? Three factors may be operat- ance to function in full scope of the Mentored by district leaders, the ing: (a) the population at Bergen role, the registered nurse is the most students can see the nursing home Pines may not have much restorative precious resource in the nursing Setting as an arena for autonomous, potential; (b) perhaps we are not home setting. challenging, and satisfying practice. looking at the right outcomes; and (c) Each student is assigned to a district maybe it just takes more time to see References and works for most of the semester change. But we have begun to see i. Behm, R. M. A special recipe to banish constipation. Geriatr.Nurs. 6(4):216-217, July-Aug. 1985. with the residents and staff of that small changes and gains. district. Ultimately, the district leadOne district leader eliminated the er steps back and the student is given need for enemas from her district by Editor's Note: The affiliation depractice in managing the district. using a Special Recipe for constipa- scribed here ended officially in JanuEach student is also required to in- tion(I). She is now working on reduc- ary 1986. Some changes may have stitute an improvement in her dis- ing intake of cathartic drugs. been made since then. tivities: research and publishing; community service and professional organization activities; and professional development. Resident care management had been the predominant responsibility of the head nurse. They were expected to direct, supervise, and participate in all phases of the nursing process with the residents and nursing staffon their assigned unit. With district nursing, responsibilities of the head nurse either complement or overlap responsibilities of both clinical directors and district leaders and include more human resource and unit management functions than ever before.
144 Geriatric Nursing May/June 1987
Long-Term-CareSetting Even with limited RN staffing, professional supervision and planning of care is possible. JOANNE PATTERSON All nursing home care should be directly supervised and planned by a professional nurse. This belief was the basis for the development of what we called "district nursing" at Bergen Pines County Hospital, after the long-term-care division at this facility became the teaching nursing home for Rutgers University College of Nursing.* *This formal affiliation was jointly supported by the Robert Wood Johnson Foundation and the American Academy of Nursing. Each site organized its program to meet their needs while meeting the objectives of the project. Joanne Patterson, RN, MS, was clinical director and member of the faculty of Rutgers University/Bergen Pines Hospital Teaching Nursing Home Project. She is now a member of the faculty of Rutgers University College of Nursing, Newark, NJ.
142 Geriatric Nursing May/June 1987
The 1~2nursing home units at Bergen Pines were divided into districts with approximately 15 residents in each. A patient classification system was used to estimate residents' nursing needs and to balance the assignment of residents and nursing personnel to the districts. Because of economic constraints, the number of registered nurses within our division had peaked at a level which allowed for one registered nurse per district; this RN was named district leader and assumed 24-hour-a-day, 7-daya-week accountability for the clinical management of all residents within his or her district. Within a short time, district nursing resulted in changes in three areas: performance of registered nurses; roles of the head nurse and clinical director; and attitudes of undergraduate nursing students assigned to the long-term-care division for clinical experience. Performance of RNs Each district leader works from 7:00 AM tO 3:30 PM, the time when
most resident activity, interdisciplinary interaction, and decision making takes place. Nursing statfon other shifts implement the district leaders' care plan, monitor residents' responses to these plans, transmit this information to their district leader, and propose modifications when necessary. As district leaders, registered nurses in the long-term-care division are responsible for resident care, management, advocacy, resident and family education, quality assurance, and professional development. This differs from the task-oriented functional role of assigning nursing personnel in which RNs were rotated through a series of selected assignments such as administering medications and treatments, bedside care, and unit administrationm"the desk"--without the benefit of continuity of assignment or the opportunity to be accountable for the total nursing care of any particular resident. Resident care responsibilities are not only more comprehensive but
have been expanded to include knowing the resident classification system and serving as a multidisciplinary team member. District leaders are now also accountable for an array of management functions, the most important of which are assigning and directing resident care, communicating pertinent information to district members, and participating in the evaluation of ancillary personnel assigned to them. This new position also requires that district leaders assume the role of resident advocate, previously considered a function of the head nurse. With the responsibilities of resident and family education comes the accountability for the quality of the education the district leaders provide (for example, its timeliness and relevance). Rather than head nurses, district leaders initiate family meetings and see the family more as "clients" rather than as "adversaries." In addition, district leaders constitute most of the membership on the Long-Term-Care Quality Assurance Committee, once a function of the head nurse, and are responsible for monitoring and evaluating standards of care. Interdisciplinary communication has greatly improved since district leaders now participate in the regularly scheduled interdisciplinary care-planning conferences. Because other disciplines deal primarily with district leaders, greater continuity, accountability, and specificity of care has resulted. The area of professional development has been the least altered. RN responsibilities remain the same except that in accordance with the status of Bergen Pines as a teaching nursing home, the registered nurse's responsibility for teaching both staff and students is specified in the job description. In units where the district model has been in place the longest (about three and a half years), the nurses are able to make decisions and move on their own initiative, more fully understanding the meaning of autonomous practice. They have become creative and personalized in their care of residents and, where possible, envision for them more than just maintenance and support.
The area most difficult for the majority of district leaders seems to be teaching and guiding the nursing attendants assigned to their districts. Where ancillary workers are noncompliant or where constructive criticism has to be shared, a reticence to get involved persists. Because managerial functions have been the most difficult for district leaders, an educational program was designed to teach the knowledge
Rutgers" faculty. Thus, clinical directors had to divide their efforts between service agency responsibilities and clinical teaching and other duties associated with the faculty role. In addition, at the start of the program clinical directors also were to assume the role of primary health care provider for the 120 residents on their assigned units. In view of time constraints, it soon became evident they could not perform as initially
Students began to see the opportunities for autonomous, challenging, and satisfying practice: here they could really make a difference.
and skills necessary to evaluate sub- projected. Instead, the clinical direcordinates, deal with conflict resolu- tors proposed the idea of delegating tion, delegate work, and be assertive some of these primary care duties to in exercising one's rights and respon- district leaders. sibilities. Since the district leaders are in intiThis "Leadership and Manage- mate association with a limited numment Series for District Leaders" ber of residents, the clinical directors consisted of 3 three-hour workshops, believed that stabilized chronic illfocusing on managerial functions ness could be monitored and disease (planning, directing, controlling, and prevention and health promotion coordinating); leadership styles; could be well Served within their women in leadership roles; group dy- scope of practice as registered nurses. namics; effective communication; The clinical skills essential to this reduction of situational stress (con- role are best taught formally through flict resolution, time management, a physical assessment course proprioritizing, problem solving, and vided by the Rutgers College of Nurspeer support); change theory; partici- ing Continuing Education Program patory management; and perform- and informally through bedside ance appraisal. It was later desig- teaching provided by clinical direcnated as mandatory for all district tors. The clinical directors schedule leaders and is now included in the their time according to the needs of standard orientation given to all new their assigned units. registered nurses. This turn of events influenced the design of the clinical directors' role Roles of Clinical Director which includes: formal education of and Head Nurse students; resident care management: District nursing and the subse- developing, enforcing, and evaluatquent evolution of registered nurse ing the standard of nursing care and responsibilities at Bergen Pines directing the nursing management of changed the roles of clinical director complex clinical situations; human and head nurse. At the outset of the resource management: developing affiliation between Bergen Pines and and evaluating nursing staff; unit Rutgers, masters' prepared clinicians management: assisting in the develwere designated as clinical directors opment of unit budgets and in the deand held authority for the clinical velopment, application, and promoprogram in assigned geographic areas tion of quality assurance and risk of the division; they also served as management programs; scholarly ac-
Geriatric Nursing May/June 1987 143
Another district leader successfultrict. Two students constructed a customized chair for a resident, which ly intervened with an apathetic, soprovided him with a means of here- cially withdrawn, elderly resident tofore unavailable mobility; one stu- who refused to eat and was steadily dent developed an oral hygiene pro- losing weight. After seven months, gram for residents in her district; and this resident gained 13 lbs, goes out three students reorganized the socially on trips sponsored by R e nurse's desk on the unit to promote creation Therapy, and has become a greater efficiency and easier retrieval source ofcomfort and support to others on the unit. of information. Another district leader eliminated Essentially, we found that students tire quickly of the task-oriented func- an elderly polio victim's dependence tions of the registered nurse (that is on routine (every four hours) Dardistributing medications, doing yon through individualized care. treatments, and taking off orders), This resident rarely requests even but they are challenged by personnel Tylenol, is pain free, more alert, and management, the primary health engages in social activities and relacare role, and these improvement tionships. Still another district leader sucprojects. They seem to see this cliniAttitudes of Students cal experience as their opportunity to cessfully intervened to facilitate an Perhaps the most interesting and make a difference. elderly resident's adjustment to her significant outcome to emerge after new colostomy. This resident's iniConclusion tial reaction of denial and fear has the advent of a program such as disWhat is obviously missing in this now changed to some degree of actrict nursing is the gradual change in attitudes of advanced undergraduate account of changes with the devel- ceptance (that is, she handles the nursing students toward placement opment of district nursing is an ac- equipment, discusses her care, tells in the long-term-care division for count of spectacular improvements staff when colostomy care is needed, clinical experience. In past years, un- in outcomes of care. Divisionwide and participates socially to a much dergraduate students perceived long- we cannot say that there have been greater degree). term care as an inappropriate clinical sweeping changes in the resident Small victories like these are taking place all over the long-term-care division at Bergen Pines. The best parts of a phenomenon such as this are that staffcan identify the changes Given the opportunity, support, and guidance and realize that they have been instrumental in bringing them about. to use all their skills, RNs can become the most Through such vehicles as the "Long important resource in the nursing home setting. Term Care Nurse Forum" and "Bright Ideas" conference, staff are able to share their experiences with colleagues. It is our belief that if our efforts at setting for their final semester of population: the discharge rate is still study in nursing theory, manage- the same; the self-care population is upgrading and expanding the role of ment, change theory, and profession- still small; and the majority of the registered nurses within long-term al socialization. With district leaders residents still suffer from confusion, care accomplished one crucial thing, in place, students enthusiastically ac- impaired mobility, incontinence, it was to empower them. Once given the opportunity, support, and guidcepted clinical placement in the divi- and the like. sion. Why? Three factors may be operat- ance to function in full scope of the Mentored by district leaders, the ing: (a) the population at Bergen role, the registered nurse is the most students can see the nursing home Pines may not have much restorative precious resource in the nursing Setting as an arena for autonomous, potential; (b) perhaps we are not home setting. challenging, and satisfying practice. looking at the right outcomes; and (c) Each student is assigned to a district maybe it just takes more time to see References and works for most of the semester change. But we have begun to see i. Behm, R. M. A special recipe to banish constipation. Geriatr.Nurs. 6(4):216-217, July-Aug. 1985. with the residents and staff of that small changes and gains. district. Ultimately, the district leadOne district leader eliminated the er steps back and the student is given need for enemas from her district by Editor's Note: The affiliation depractice in managing the district. using a Special Recipe for constipa- scribed here ended officially in JanuEach student is also required to in- tion(I). She is now working on reduc- ary 1986. Some changes may have stitute an improvement in her dis- ing intake of cathartic drugs. been made since then. tivities: research and publishing; community service and professional organization activities; and professional development. Resident care management had been the predominant responsibility of the head nurse. They were expected to direct, supervise, and participate in all phases of the nursing process with the residents and nursing staffon their assigned unit. With district nursing, responsibilities of the head nurse either complement or overlap responsibilities of both clinical directors and district leaders and include more human resource and unit management functions than ever before.
144 Geriatric Nursing May/June 1987