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The Future of Nursing in Assisted Living
OFFICIAL SECTION OF THE
American Assisted Living Nurses Association
The Future of Nursing in Assisted Living
ples and implications of how these recommendations apply to the practice of nursing in assisted living.
Josh Allen, RN, C-AL Chair, American Assisted Living Nurses Association
Achieve Higher Levels of Education and Training
The health care system in the United States is at a crossroads. Can we meet the needs of the aging baby boomers, 10,000 of whom are turning 65 every day? Will health care reform result in changes that improve both the quality and efficiency of care delivery? How does assisted living fit into the picture? Many questions are yet unanswered, but one fact is clear: nurses have an opportunity to be part of the solution. Nurses make up the largest component of the health care workforce and therefore play a critical role in shaping our health care system as it attempts to accommodate the demands of our rapidly aging population in the face of economic realities that require controlling the cost of care. In 2011, the Institute of Medicine (IOM) published a landmark report titled The Future of Nursing: Leading Change, Advancing Health; this publication attempts to identify the roles “nursing can assume to address the increasing demand for safe, high-quality, and effective health care services.” The report provides recommendations organized around 4 key messages:1 1. Nurses should practice to the full extent of their education and training. 2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 3. Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. 4. Effective workforce planning and policy making require better data collection and an improved information infrastructure. Although assisted living is mentioned only once in the 700-page report, these recommendations ring loud and clear for nurses working in assisted living, residential care, and long-term care. This article attempts to identify specific exam-
416
Advancing one’s education is a challenge for many nurses. When a new nurse fresh out of school gets his or her first job, there is often no looking back. It is easy to become stuck in the rut of the day-to-day, and although we may promise ourselves we will go back to school, it all too often never happens. Assisted living nurses often find themselves in management or leadership positions, such as a department head, administrator, executive director, or corporate/regional position. Further education in management or business can prepare a nurse to take on the challenges of budgeting, human resources, marketing, and other skills that are not often part of basic nursing education. Although maximizing one’s career potential in assisted living may not require advanced nursing education, certifications, or degrees, there are other examples of how additional education and training can improve a nurse’s ability to earn promotions, grow within his or her organization, or explore other professional opportunities within the industry. Higher levels of education do not have to mean going back to school in the traditional sense. There are several certifications, for example, that can arm a nurse with knowledge and skills that are important in assisted living, including the following: Administrator/manager certification: many state assisted living regulations require specialized training or certification for individuals managing an assisted living community. Completing such a program provides important foundational knowledge of regulatory and policy requirements in that particular state.2 Assisted living nurse certification: the American Assisted Living Nurses Association administers and maintains an assisted living nurse certification program that verifies a nurse has thorough knowledge of the scope and standards of assisted living nursing practice.
Geriatric Nursing, Volume 33, Number 5
National assisted living/residential care administrator certification examination, administered by the National Association of Long Term Care Administrator Boards.
Full Partners The IOM report calls for nurses to be “full partners, with physicians and other health professionals, in redesigning health care in the United States.” There is perhaps no better example of a setting in which this full partnership is more critical than in assisted living. Assisted living nurses work with tremendous levels of autonomy, often working as the only nurse in a particular community or organization. Yet despite this autonomy, nurses are charged with managing the health care needs for a resident population with increasing levels of acuity.3 Assisted living nurses must effectively collaborate with health professionals across the spectrum to ensure the safety, quality, and dignity in care that each assisted living resident deserves. This includes partnerships with physicians to ensure access to assessments, diagnoses, and orders; partnering with home health and hospice organizations to coordinate care in the assisted living community; and improving collaboration with health care systems to reduce unnecessary rehospitalizations as mandated by elements of the Affordable Care Act. However, being full partners goes beyond the “bedside” and extends into policy decisions that will directly shape the future of assisted living. Relative to other health care settings, assisting livingdand its corresponding regulationsdis still in the early stages of development. States are still shaping the regulatory framework that outlines care delivery in this setting, and many states have yet to resolve how nurse practice acts relate to and have an impact on assisted living regulations and policy. This represents a critical opportunity for nurses to take a leadership role by applying our practical experience and expertise to help direct the future of assisted living. Unfortunately, as identified in the report, all too often nurses do not see policy making as part of their role or skill set: Being a full partner transcends all levels of the nursing profession and requires leadership skills and competencies that must be applied within the profession and in collaboration with other
Geriatric Nursing, Volume 33, Number 5
health professionals. In care environments, being a full partner involves taking responsibility for identifying problems and areas of waste, devising and implementing a plan for improvement, tracking improvement over time, and making necessary adjustments to realize established goals. Moreover, being a full partner translates more broadly to the health policy arena. To be effective in reconceptualized roles, nurses must see policy as something they can shape rather than something that happens to them. Nurses should have a voice in health policy decision making and be engaged in implementation efforts related to health care reform. Nurses also should serve actively on advisory committees, commissions, and boards where policy decisions are made to advance health systems to improve patient care.
Better Data Collection for Workforce Planning How many nurses are working in assisted living? Where are they employed and in what roles? What activities do they perform? Answering these and other questions about the assisted living workforce will be important to achieve a balance of skills and perspectives among nurses and other health professionals that will support a “transformation of the health care system and the practice environment.”
Practice the Full Extent of Our Education and Training Nurses have demonstrated a unique ability to lead innovative strategies to meeting the health care needs of assisted living residents. These innovations have enabled residents to lengthen their stay in assisted living, in accordance with their wishes, while recognizing improvements in overall health and functional levels. However, many state assisted living regulations create barriers that prevent a nurse from practicing to the fullest extent of his or her licensure, education, and training when working in assisted living. For example, in Californiadhome to more than 20% of the assisted living communities in the United Statesdthe state’s assisted living regulations require that a physician be contacted before giving each dose of a PRN (“as needed”) medication if a resident is unable to communicate his or
417
her symptoms, even if the person giving the medication is a licensed or registered nurse. The idea that a nurse ceases to be a nurse simply because he or she crosses the door into an assisted living community suggests that as nurses we are unable to exercise the necessary professional judgment to utilize our knowledge and expertise safely and appropriately. If assisted living is to keep pace with growing consumer demands for higher levels of care and fewer transitions to other health care settings, scope-of-practice and assisted living regulations must be reconciled at the state level. States would be well served to look to progressive states, such as Oregon and Washington, which have addressed these challenges through clearly defined nurse delegation rules and regulations.
Summary As nurses we will play a critical role in the ongoing transformation of our health care system as it attempts to meet the needs of the aging U.S. population. The IOM future of nursing report provides a framework for tackling some of the challenges that could prevent full realization of the goals of health care reform and the increased emphasis on person centered care strategies.
418
About AALNA The American Assisted Living Nurses Association is the only national nonprofit association dedicated exclusively to nursing in assisted living, operated by nurses, for nurses. The mission of AALNA is to promote effective nursing practice in assisted living such that nurses as well as residents benefit. Learn more about AALNA at www.alnursing.org.
References 1. Institute of Medicine. The future of nursing: leading change, advancing health. Washington, DC: The National Academies Press; 2011. 2. Assisted living state regulatory review. Washington, DC: National Center for Assisted Living; 2012. 3. Park-Lee E, Caffrey C, Sengupta M, et al. Residential care facilities: a key sector in the spectrum of long-term care providers in the United States. Washington, DC: National Center for Health Statistics; 2011. JOSH ALLEN, RN, C-AL, is a Registered Nurse with more than 20 years of experience in assisted living and residential care. Josh is the Board Chair of the American Assisted Living Nurses Association, Napa, CA, and represents AALNA as the Chairperson of the Center for Excellence in Assisted Living. 0197-4572/$ - see front matter Ó 2012 Published by Mosby, Inc. http://dx.doi.org/10.1016/j.gerinurse.2012.07.009
Geriatric Nursing, Volume 33, Number 5
American Assisted Living Nurses Association
The Future of Nursing in Assisted Living
ples and implications of how these recommendations apply to the practice of nursing in assisted living.
Josh Allen, RN, C-AL Chair, American Assisted Living Nurses Association
Achieve Higher Levels of Education and Training
The health care system in the United States is at a crossroads. Can we meet the needs of the aging baby boomers, 10,000 of whom are turning 65 every day? Will health care reform result in changes that improve both the quality and efficiency of care delivery? How does assisted living fit into the picture? Many questions are yet unanswered, but one fact is clear: nurses have an opportunity to be part of the solution. Nurses make up the largest component of the health care workforce and therefore play a critical role in shaping our health care system as it attempts to accommodate the demands of our rapidly aging population in the face of economic realities that require controlling the cost of care. In 2011, the Institute of Medicine (IOM) published a landmark report titled The Future of Nursing: Leading Change, Advancing Health; this publication attempts to identify the roles “nursing can assume to address the increasing demand for safe, high-quality, and effective health care services.” The report provides recommendations organized around 4 key messages:1 1. Nurses should practice to the full extent of their education and training. 2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 3. Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. 4. Effective workforce planning and policy making require better data collection and an improved information infrastructure. Although assisted living is mentioned only once in the 700-page report, these recommendations ring loud and clear for nurses working in assisted living, residential care, and long-term care. This article attempts to identify specific exam-
416
Advancing one’s education is a challenge for many nurses. When a new nurse fresh out of school gets his or her first job, there is often no looking back. It is easy to become stuck in the rut of the day-to-day, and although we may promise ourselves we will go back to school, it all too often never happens. Assisted living nurses often find themselves in management or leadership positions, such as a department head, administrator, executive director, or corporate/regional position. Further education in management or business can prepare a nurse to take on the challenges of budgeting, human resources, marketing, and other skills that are not often part of basic nursing education. Although maximizing one’s career potential in assisted living may not require advanced nursing education, certifications, or degrees, there are other examples of how additional education and training can improve a nurse’s ability to earn promotions, grow within his or her organization, or explore other professional opportunities within the industry. Higher levels of education do not have to mean going back to school in the traditional sense. There are several certifications, for example, that can arm a nurse with knowledge and skills that are important in assisted living, including the following: Administrator/manager certification: many state assisted living regulations require specialized training or certification for individuals managing an assisted living community. Completing such a program provides important foundational knowledge of regulatory and policy requirements in that particular state.2 Assisted living nurse certification: the American Assisted Living Nurses Association administers and maintains an assisted living nurse certification program that verifies a nurse has thorough knowledge of the scope and standards of assisted living nursing practice.
Geriatric Nursing, Volume 33, Number 5
National assisted living/residential care administrator certification examination, administered by the National Association of Long Term Care Administrator Boards.
Full Partners The IOM report calls for nurses to be “full partners, with physicians and other health professionals, in redesigning health care in the United States.” There is perhaps no better example of a setting in which this full partnership is more critical than in assisted living. Assisted living nurses work with tremendous levels of autonomy, often working as the only nurse in a particular community or organization. Yet despite this autonomy, nurses are charged with managing the health care needs for a resident population with increasing levels of acuity.3 Assisted living nurses must effectively collaborate with health professionals across the spectrum to ensure the safety, quality, and dignity in care that each assisted living resident deserves. This includes partnerships with physicians to ensure access to assessments, diagnoses, and orders; partnering with home health and hospice organizations to coordinate care in the assisted living community; and improving collaboration with health care systems to reduce unnecessary rehospitalizations as mandated by elements of the Affordable Care Act. However, being full partners goes beyond the “bedside” and extends into policy decisions that will directly shape the future of assisted living. Relative to other health care settings, assisting livingdand its corresponding regulationsdis still in the early stages of development. States are still shaping the regulatory framework that outlines care delivery in this setting, and many states have yet to resolve how nurse practice acts relate to and have an impact on assisted living regulations and policy. This represents a critical opportunity for nurses to take a leadership role by applying our practical experience and expertise to help direct the future of assisted living. Unfortunately, as identified in the report, all too often nurses do not see policy making as part of their role or skill set: Being a full partner transcends all levels of the nursing profession and requires leadership skills and competencies that must be applied within the profession and in collaboration with other
Geriatric Nursing, Volume 33, Number 5
health professionals. In care environments, being a full partner involves taking responsibility for identifying problems and areas of waste, devising and implementing a plan for improvement, tracking improvement over time, and making necessary adjustments to realize established goals. Moreover, being a full partner translates more broadly to the health policy arena. To be effective in reconceptualized roles, nurses must see policy as something they can shape rather than something that happens to them. Nurses should have a voice in health policy decision making and be engaged in implementation efforts related to health care reform. Nurses also should serve actively on advisory committees, commissions, and boards where policy decisions are made to advance health systems to improve patient care.
Better Data Collection for Workforce Planning How many nurses are working in assisted living? Where are they employed and in what roles? What activities do they perform? Answering these and other questions about the assisted living workforce will be important to achieve a balance of skills and perspectives among nurses and other health professionals that will support a “transformation of the health care system and the practice environment.”
Practice the Full Extent of Our Education and Training Nurses have demonstrated a unique ability to lead innovative strategies to meeting the health care needs of assisted living residents. These innovations have enabled residents to lengthen their stay in assisted living, in accordance with their wishes, while recognizing improvements in overall health and functional levels. However, many state assisted living regulations create barriers that prevent a nurse from practicing to the fullest extent of his or her licensure, education, and training when working in assisted living. For example, in Californiadhome to more than 20% of the assisted living communities in the United Statesdthe state’s assisted living regulations require that a physician be contacted before giving each dose of a PRN (“as needed”) medication if a resident is unable to communicate his or
417
her symptoms, even if the person giving the medication is a licensed or registered nurse. The idea that a nurse ceases to be a nurse simply because he or she crosses the door into an assisted living community suggests that as nurses we are unable to exercise the necessary professional judgment to utilize our knowledge and expertise safely and appropriately. If assisted living is to keep pace with growing consumer demands for higher levels of care and fewer transitions to other health care settings, scope-of-practice and assisted living regulations must be reconciled at the state level. States would be well served to look to progressive states, such as Oregon and Washington, which have addressed these challenges through clearly defined nurse delegation rules and regulations.
Summary As nurses we will play a critical role in the ongoing transformation of our health care system as it attempts to meet the needs of the aging U.S. population. The IOM future of nursing report provides a framework for tackling some of the challenges that could prevent full realization of the goals of health care reform and the increased emphasis on person centered care strategies.
418
About AALNA The American Assisted Living Nurses Association is the only national nonprofit association dedicated exclusively to nursing in assisted living, operated by nurses, for nurses. The mission of AALNA is to promote effective nursing practice in assisted living such that nurses as well as residents benefit. Learn more about AALNA at www.alnursing.org.
References 1. Institute of Medicine. The future of nursing: leading change, advancing health. Washington, DC: The National Academies Press; 2011. 2. Assisted living state regulatory review. Washington, DC: National Center for Assisted Living; 2012. 3. Park-Lee E, Caffrey C, Sengupta M, et al. Residential care facilities: a key sector in the spectrum of long-term care providers in the United States. Washington, DC: National Center for Health Statistics; 2011. JOSH ALLEN, RN, C-AL, is a Registered Nurse with more than 20 years of experience in assisted living and residential care. Josh is the Board Chair of the American Assisted Living Nurses Association, Napa, CA, and represents AALNA as the Chairperson of the Center for Excellence in Assisted Living. 0197-4572/$ - see front matter Ó 2012 Published by Mosby, Inc. http://dx.doi.org/10.1016/j.gerinurse.2012.07.009
Geriatric Nursing, Volume 33, Number 5