How nurses are linked to nursing home quality of care

Nurse number, training, and experience have a direct impact on nursing home quality of care. Why? Nurses are critical for assessing, treating, and coordinating resident care. This week on the podcast, we welcome Dr. Mary Ellen Dellefield to discuss the importance of nursing staff for resident outcomes.

Schenk: Hello out there. Welcome back to the podcast. My name is Rob. I’m going to be your host in this episode. We are going to be dealing with the link between the quality and quantity of nursing care at a nursing home with the overall quality of care received by the resident at that nursing home. Why are the two linked? What does the nurse do? Why is the nurse’s role so important?

But we are not doing that alone. We have a guest this week, the fabulous Mary Ellen Dellefield. Dr. Dellefield has been working, writing and researching about nursing homes in the United States since 1985 – 1985, that’s when “Back To The Future” came out. That’s how long she’s been working on and researching with nursing homes. So think about the first time you saw “Back To The Future.” That’s how long she’s been dealing with nursing homes. Since 1985, she has gone on to earn a PhD at UCLA, did a John A. Hartford Fellowship at UC-SF, and is currently working at the VA San Diego Healthcare System as a research nurse scientist. She has been a charge nurse, a director of nursing, a staff development nurse, infection control nurse and an MDS coordinator nurse at various San Diego County nursing homes. She is a fellow of the American Academy of Nursing and a member of the Board of the American Association of Post Acute Care Nursing with the AAPACN. Her experience involves nurse staffing, quality, management, regulation, pressure ulcer prevention and safety, so more than qualified to talk to me. We are so excited to have her on talking about the role of the registered nurse and the link to quality of care. Dr. Dellefield, welcome to the show.

Dellefield: Thank you.

Schenk: I feel like I’m constantly researching one thing or another online and I came across your study about the link between nursing care, nursing time with residents and quality outcomes. That’s how I came to know you as I mentioned at the top of the show. And I thought it was very interesting. I was like, “Well I’ve got to have her on to talk about this,” so we can kind of at least scratch the surface on that subject.

So before we get into why nurses are important and why your studies are so important and why people should know about them, can you educate our audience about what the actual role of a registered nurse is in a nursing home? And I ask that as opposed to a CNA, an LPN, the attending physician, that sort of thing.

What role does the RN play in nursing home care?

Dellefield: Got it. Okay. Well first, I just want to make sure we’re on the same page about what a nursing home is. A nursing home is a place where people stay where you have either short term needs like rehab or they have long-term needs, perhaps they’re dying or perhaps they need some dementia care.

The second thing is what is a nurse? Who is a registered nurse? The problem with nursing is that there are lots of ways to become a nurse and the term “nurse” is used to nursing assistants, LPNs, RNs, sometimes nurse practitioners, so you don’t know who in the heck you’re talking to or should be talking to half the time. But nursing has its own set of problems as other disciplines do.

So one of those problems has an impact on nursing home care and that is that the aspiration is that by 2020, all the registered nurses who went to a diploma program or a local community college and got their RN would actually get their BSN. In acute care hospitals, most hire only BSNs. However, the market is such that in nursing homes, the non-BSN RN, that is pretty much one of the only places where she can work. Now this is not to suggest that these people are incompetent or anything else, but in terms of having a sense of what their education is, it’s helpful to know that.

And really the only reason I think it’s helpful to know that is that there are many registered nurses who are very good at practical problem solving, managing, organizing work, but they may not be so great at thinking more conceptually, because you know the nursing home is actually a very complex organization, even though when you walk in, it’s like sleepy town. You’re thinking, “Geez, they’re doing what? I mean what’s the big deal?” It actually is quite complex.

Why is the role of RN critical to quality?

Why this is important for nurses is the unique role of the registered nurse according to practice acts that each state has is that the registered nurse has the capacity by virtue of education to coordinate care so she has like the umbrella view of what in the heck is going on. So she’s a coordinator of care. She understands how the doctor, the CNA, basically all the pieces of the puzzle, she’s supposed to know how they all fit together and she’s making sure that they’re fitting together in a way that is best for the resident.

And the other thing that is a unique thing for registered nurses is that they have the capacity to perform the nursing process. Now there’s a long history about nursing process that we won’t go into, but the bottom line is that in the ‘50s, academic nursing said, “Well our claim to fame if we have a bachelor’s degree is that we can problem solve, and we call it the nursing process. We assess, plan, implement, evaluate.” That’s the whole schtick behind these care plan meetings and care planning, and I would all of the Medicare/Medicaid conditions for participation, they are all framed in the context of this care plan, care planning, the resident assessment instrument, minimum data set. You may hear it’s likely that a registered nurse will be the MDS nurse, and there’s all this paperwork and computer work, etc., etc.

So in a perfect world, the role of the nurse is to have a sort of umbrella overseeing kind of perspective of what’s going on and she knows how to integrate the work, the clinicians. And she really is – you could think of her as an information manager. She’s supposed to know what she’s doing as a nurse. She gets and receives information from her staff, the residents, the doctors, whatever, the chart, and she’s supposed to be seeing if that information is being managed well in the sense of a kind of a nursing surveillance.

And the idea of surveillance is related to safety. The idea is that RN, at least one RN in the building has the capacity to anticipate problems, to collect information about problems, to make a judgment about solving the problem and to actually make sure it’s done, whether she’s doing it or the nursing assistant is doing it, because one of the problems in nursing homes is that the nursing service consists primarily of LPNs and nursing assistants. So there’s very few registered nurses. So there’s a lot of skill involved in how does this RN conceptualize nursing service as the RN, the LPN, the CNA and everyone knows their place and is respected and grows in their role, etc., etc. So that is something that some RNs do better than others.

Some RNs will be much more the paper pushers and the CNAs the little worker bees and they’re kind of dismissive and disconnected from what the work is at the bedside. I’m being honest with you.

Schenk: Please.

Dellefield: But what’s supposed to be going on is this RN who’s responsible for staffing and the budget and hiring people and managing them and perhaps has to do some clinical work occasionally like start an IV or do a more complex treatment, she has to figure out a way to be doing that work that’s her actual job description and she’s supposed to be staying in touch with the actual work at the bedside and providing supervision surveillance to be sure that things are piping along, that there’s not a problem that’s in the process of being created that is missed.

Schenk: Right. So that’s a lot to unpack there. So I wanted to kind of touch on something you mentioned and it’s important for the audience I think to understand is that you brought up an interesting point – what is a nursing home? So nursing homes are federally regulated. If a facility is receiving Medicare/Medicaid, it has to follow a certain regulation regardless of whether you’re in Nevada, you’re in Washington State, if you’re in Tennessee, Georgia, Florida, doesn’t matter. They’re uniform. They’re uniform guidelines the nursing home has to abide by.

With regard to the qualifications of the nurse, that is not uniform at a federal level. That is state-specific. So as Dr. Dellefield mentioned, there are educational requirements or compliance requirements or criteria that might be different from state-to-state, which I would argue, and I’m not saying Dr. Dellefield is arguing this, I would say that is a problem because the level of care that one nurse might be able to provide based on their education, training and the criteria for compliance in one state might not be as good in another state.

Dellefield: Yes.

Schenk: So that’s an issue with that. But I wanted to hit home what you had said and that is one of the critical roles of the registered nurse, whatever we’re calling the registered nurse, whatever your state you’re in, is that coordination of care, which comprises of assessment, implementation of that care plan and revising that care plan, I mean that’s the “nursing process.”

Dellefield: Exactly.

Schenk: Right? So when you have that nurse that’s, “Well I am an administrator, so I’m pushing pencils, I’m HR, I hire people and the CNAs do everything,” I would assume that that’s a problem. So can you, and that’s what I think I would love to get your understanding of why is it that if nursing home care suffers or if there’s not – I’m sorry – if nursing care suffers or there is not enough nursing care, either one, pick one, why does that inevitably lead to problems?

What do studies say about the amount of time RNs should spend with a resident?

Dellefield: Okay. Well that’s a good question. Okay. Nursing care really has two parts. It’s the technical part, and that would be like bathing someone, feeding them, the LPNs giving pills. So the RN, if she’s not paying attention to the technical part that others are doing, it’s a problem. Now how she pays attention is up to her, right? She can’t watch every day. She has to have some sort of system of care where she can keep track of these sort of high-risk events.

The other part of the nurse’s role is interpersonal, and this interpersonal role is shared by the LPN, the CNA – as you can imagine, it’s a service industry, people need interpersonal skills. But that touches on sort of like the customer service, the problem-solving, the knowing how to deal with employees. If you’re like Nurse Ratched, a lot of it is those two skill sets of the registered nurse, and the reality is federally, there’s no requirement for you to have just about anything. I’m exaggerating – you need to have an RN license. You don’t need to have any experience. You don’t have to pass a certification test. We’re trying to get that to happen, but it is not a requirement.

So a lot of the care is routine and goes on over time, today, tomorrow, the next day, blah-blah-blah, okay? Well while that’s going on, if there’s a problem cropping up and there’s no one paying attention to it because they’re too busy just doing the chore – “I did give her a bath. I did give her pills. I did this. I did that. I called the doctor” – but if there’s not a person looking over to see what’s the trend here, like maybe there’s a problem here, and that’s how the RN is related to quality.

What do studies say about the impact of RN time to positive outcomes?

And some of the outcomes, some of the patient experiences that are enhanced with more RNs are lower pressure ulcers. Why is that? Because pressure ulcers occur over time and they involve bathing, nutrition, positioning, so that whole kind of care that’s going on day in and day out. Infections – same kind of deal. Older people tend to have behavioral manifestations of infections, so it may be that it’s more subtle. It’s not just a matter of their temperature going up. And the CNA may notice something and say something to the RN, and the RN is supposed to really value what comes out of the CNA’s mouth. Unfortunately for a variety of reasons, sometimes there’s not the greatest relationship between the information that the CNA has and her opportunities to communicate that to the RN. I mean that’s just a fact. You can see that in citations. It’s a problem.

So anything that a family member can do to try to read, get a sense of how are these guys getting along – I know it’s not your problem to care about the employees but you want to get a vibe for, “Does this seem like a place that people can talk to one another, they’re not scared of doing a mistake?”

Okay, so pressure ulcers, infection control, the other thing is behavioral problems. Like with dementia, these complex behavioral issues require a lot of trial and error, and that may be with drugs, with a psychiatrist, the physician, it may be behavioral that the nursing team is trying different things to see if this approach works better than that approach. There might be a psychologist in the facility if you’re lucky. So these are all things that are happening over time and one would hope that there’s an educated registered nurse who’s supposed to understand all of that and can provide suggestions about when the care plan needs to be changed.

Schenk: That makes absolute sense in terms of that’s one of the direct links, if not the primary link, between the nurse and negative outcomes, meaning something bad has happened like a pressure injury. It’s because there’s a difference between assessing someone in a holistic sense, as you mentioned, a fever, behavioral – maybe they’re getting up and walking, pain in the abdomen. And so a CNA typically is only trained to provide personal services and “observe.” So the CNA might observe, “Hey, Mr. Johnson is being combative and he’s tender in his abdomen and his body temperature is above baseline.” That’s observed, right? But that CNA may not necessarily qualified – not qualified, but maybe doesn’t understand in terms of the assessment, “Oh, we might have a UTI here.” That’s the nurse, right? So the nurse is supposed to take all that observed information and compute it and go, “Okay, this is probably what’s going on,” which I guess is different than diagnosing something, but there’s an assessment process, and if the assessment process is broken, the nursing process is broken, then there’s going to be more negative outcomes.

Dellefield: And I just have to say that besides obsessing about the care plan, which we tend to do, the care, that stuff actually has to be done.

Schenk: Oh right. Yeah. Yeah, if you don’t follow the plan, you plan to fail or whatever that is, that saying. So Dr. Dellefield, let me ask you this. In all of your studies, you have extensive experience in this subject, do you have any recommendations for how we can improve or how we can reform nursing so that we get better quality of care? Is there anything, a couple of things we can do just right off the bat, maybe systematically, maybe not systematically that can improve quality of care through nursing?

Are there any reforms that can increase nursing home quality (i.e. updating MDS, more RN time, etc)?

Dellefield: Well that’s a good question. The Centers for Medicare and Medicaid Advocacy have been working over the years to try to make nursing homes and nursing care better. They’ve tried lawsuits, class action lawsuits, regulatory reform, scholarship, and what’s difficult is that to improve nursing care, nursing home care simply does require resources as in money. And the money might come in the form of the registered nurse needs to actually have been certified, so that means she has to pay for a course or the company pays for the course for her to be certified. That’s one thing.

Secondly, the wages are really significantly lower for all the staff including RNs. RNs in hospitals get a lot of money now, so why would you work in the nursing home if you could earn more money, have better benefits?

The third thing is because since 1965, we’ve focused on making rules and regulations as a way to advance quality and consumer advocacy rather than investing money, sometimes the nursing home itself is not the most pleasant place for people to work or for an RN to practice. So she’s earning less money, to do it well – I have to tell you, I’ve been a manager in acute care, I can tell you hands down the director of nursing job is the most complex, challenging job there is in my experience and observations.

You could advocate each state, as you mentioned, you could see what the state, the hours are for RNs, what’s the requirement, and you could advocate to improve that. What we’re trying to do nationally but it seems rather unlikely is to get an RN on each shift, and at the very least an RN on the day shift and the evening shift. And that’s not a requirement now. There’s like 45 minutes of RN care per day that a patient gets, and you have to remember that care is divided into three shifts. That’s counting all the RN tasks, like she’s hiring people, firing them, right? That’s all this indirect care plus direct care. So in other words, it’s not very much time and I have to tell you, there is not enough time to do what the regulations require. The regulations are fine. It’s that the resources aren’t there and then the enforcement is counterproductive in my humble opinion. It hasn’t really moved the needle.

Schenk: Okay, so what do you mean by that? Should there be a stronger enforcement mechanism like surveying twice a year, something like that?

Dellefield: Advocates are very into more regulation. My perspective as a nurse and a researcher, it would be better if the evidence to determine compliance with the regulations wasn’t so obsessively focused on documentation. That was supposed to change since 1990, but it’s only gotten worse. And the more you want people to document, the less anyone has time to do care, and this is especially true for the registered nurse. So it would be advocating as a consumer for whatever regulatory changes are made to make sure that they are feasible to implement, they are simple, because now, here’s this book.

Schenk: Right. I’m assuming you’re holding up – those are the regs. Those are the federal regulations.

Dellefield: Yes. You know, it’s unworkable. Seriously. I think it’s over-the-top crazy, and that’s what I hear from my director of nursing friends who oversee chains of nursing homes. So back to what they could do, as you become educated about what’s keeping the RN back, you could look at your state care hours. You could advocate for support of any legislation where there’s at least the increased presence of an RN federally or anything to increase the educational requirement because some of these nurses, they just are in over their heads. They’re good people. They’re competent in many ways, but they really are lacking some skills. And you see that in these bad outcomes, like a person strangling themselves on a siderail, like someone getting a pressure ulcer. I’ve read citations about people wandering and then they found them frozen in a freezer. I mean it’s one thing to have policies and procedures, but the RN needs to actually know what they are and how to use them, and she’s using them by working with her staff. So if she can’t get along with her staff and is not an effective manager, it’s very hard to see how quality in nursing homes is going to improve. I guess I really truly would say that’s the bottom line. It’s a sophisticated management job and it requires a good amount of skill and if you don’t have it…

Schenk: Yeah, then you might be toast, or at least there’d be bad outcomes more likely.

Dellefield: Yes.

Schenk: Dr. Dellefield, we so much appreciate you coming on, sharing your knowledge, sharing your perspective on some solid reforms for nursing and nursing homes. And thank you so much.

Dellefield: Oh sure. Thank you.

Schenk: What a great episode. At least in my opinion, Dr. Dellefield brought some great information. Such a wealth of knowledge. I feel like we could talk for hours and hours. So if you also feel that way, if you feel this was an awesome episode, then be sure to like and subscribe wherever you get your podcasts from. Go over to our YouTube channel, hit the subscribe button, hit the notification bell, leave a comment while you’re at it. If you’ve got suggestions for content that you want to hear in future episodes, let us know. You can either leave a comment on YouTube or email us and we will attempt to get to that subject matter in the future. New episodes every other week, that is two times a month, wherever you get your podcasts from, on Mondays, that’s when they are published. And with that, folks, we will see you next time.