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Thanks to a growing population and the newly introduced National Disability Insurance Scheme, the health and medical sector is set to experience extremely promising growth in the coming years to —with midwives and nurses particularly strong at 2. By , the number of Registered Nurses RNs is expected to skyrocket, from around , in to in excess of , With just two years of studying a Diploma of Nursing HLT , students can become qualified as an Enrolled Nurse, a role which is also expected to grow over the coming five years.

In terms of placement, most people associate nurses with working at their local hospitals. However, you can also find employment in schools, government agencies and home care facilities. When it comes to career pathways, nursing is just as varied. If you like the idea of helping people recover from illness or injury, rehabilitation is a rewarding career pathway. You can also consider mental health, midwifery or community care. This can be a great first step in your career, giving you the experience needed to further your study with a Diploma of Nursing HLT You might start off as an Assistant in Nursing, working under the supervision of a Registered Nurse.

On the other hand, you might aim towards becoming a Nurse Manager or Nurse Educator.

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Simply put, there are many paths to choose from. Handling this pressure can pose a real challenge, but if you like a fast-paced environment with lots of variety, then nursing as a profession could be right for you. Residents are entitled to a private apartment shared only by choice that includes a kitchen, a bath with roll-in shower, locking doors, and temperature control capability. Routine nursing services and case management for ancillary services are provided. Data show that residents in these Oregon assisted-living facilities have a remarkably high level of disability: 84 percent have some mobility impairment, 75 percent require assistance with medications, and 63 percent require assistance with bathing.

Most importantly, the orientation of staff toward the residents is to empower them by sharing responsibilities, enhancing choices, and managing risks Wilson, Because of the lack of regulations and standards, consumers need to question providers about all aspects of services, including the philosophy of care, number and type of staff, staff training, staff supervision, and costs, to determine if resident and family needs will be met. The sub-acute unit is another alternative long-term-care model.

With the advent of the Medicare prospective payment system and use of diagnosis-related groups DRG as the basis for payment in hospitals, older adults began to be discharged "quicker and sicker" to nursing homes. In the United States, this early discharge of older adults from hospitals has led to a movement to create sub-acute care units in nursing homes, discussed more fully below in "Future Demand for Institutional Long-term Care. According to Fries , case-mix refers to distinctions of residents related to resource use where resource use is primarily defined as a ratio of nursing time to costs.

Nursing home residents are a heterogeneous mix of vulnerable adults whose ages may span more than 50 years. Residents are also getting older; those over the age of 85 years constitute about 42 percent of nursing home residents, up from 34 percent in Despite the dramatic increase in the number of nursing home residents who are age 85 or older, there are more than , 12 percent residents under the age of 65 in nursing homes McKnight's Long-term Care News , As noted earlier, a high percentage around 75 percent of persons who reside in nursing homes are reported to suffer from a chronic dementing process or some form of mental health or behavioral alteration.

Most of these residents also have medical and personal care needs that require ongoing staff intervention and support. For example, about half 51 percent of residents are incontinent of urine. Physical care issues, low staff ratios, regulatory issues, and inadequate staff preparation and training often mean that residents with behavioral impairment are still poorly understood and tolerated in the long-term-care environment Hall, Over the past few years, a paradigm shift has occurred in long-term care—from a biomedical treatment orientation and custodial care approach to a more social-behavioral model of care with a rehabilitative focus Burgio and Scilley, However, implementation of a social-behavioral model of care has been constrained by regulations and reimbursement that are still guided by a medical model and by tensions between federal and state jurisdictions for regulating and reimbursing nursing homes.

Issues of staffing and care policies in traditional long-term-care facilities are influenced by a combination of federal and state regulations. Because the federal government is the only payer for Medicare and shares the rapidly increasing payment with states for Medicaid, and because consumer concerns intensified, federal interest in regulation increased and resulted in the passage of OBRA Yet state regulatory groups did not control the development of OBRA regulations and do not have the option to not implement them. The OBRA 87 regulations mandated higher standards for quality care, but federal and individual state reimbursement formulas have not necessarily changed to enable nursing homes to better meet the higher standards.

Enactment of OBRA 87 resulted in regulations that required nursing homes to adopt a more active social-behavioral treatment model for residents. In contrast to an earlier emphasis on facility cleanliness and the physical plant, the new regulations are more resident focused, emphasizing systematic assessment and individual plans of care that foster the highest achievable level of resident well-being.

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In addition to restricting the use of antipsychotic medications for the treatment of behavioral problems, OBRA also mandated more training for each nurse's aide a minimum of 75 hours of initial training that addresses psychosocial as well and physical health care, and 12 hours of in-service education annually , as well as assurance of skill competency Burgio and Scilley, Thus, with OBRA 87 setting the standard for quality of care in long-term-care facilities, the nursing home industry today is among the most highly regulated businesses in America.

Beset with regulations developed in response to perceived abuses and poor quality care, licensed nursing homes are charged with providing care that meets the vast needs of diverse residents, yet often they must try to meet that charge with only minimum reimbursement and inadequate staffing Hall, Success or failure to meet the government mandates is evaluated by the facility's own quality assurance programs, as well as surveys conducted by multiple agencies, care review boards, and state ombudspersons who investigate complaints Hall, A report by the Department of Health and Human Services Office of the Inspection General indicates that most states are doing an adequate job of carrying out their survey responsibilities as outlined under OBRA However, survey staff issues, enforcement, and inspections remain problematic, and there is need for improved training of state surveyors.

In addition to the surveying difficulties, the lack of attention to how reimbursement affects the ability of homes to meet quality standards is a serious concern. Nationally, there is some movement toward case-mix reimbursement for nursing home care, although most states continue currently to reimburse by capitated cost-based systems—systems that are limited by a cap regardless of the cost to provide the care.

Use of this system tends to encourage nursing homes to preferentially accept private pay and minimal care persons, rather than persons whose care is reimbursed by Medicaid. The lack of federal regulation coupled with wide variation in state regulations also affects alternative forms of long-term-care facilities and the level of reimbursement available to those facilities. Currently there are few regulations for assisted-living facilities, and reimbursement under Title XIX for assisted living is limited to a few states. Public expenditures for community-based services are relatively small compared to those for nursing home care O'Shaunessy and Price, Medicaid, which is the principal source of funding of health care services for low income persons, finances mostly nursing home care and was not designed to support a full array of social and other long-term-care community-based services.

A few states provide some reimbursement, but because of a lack of Medicaid reimbursement most deny persons who cannot privately pay for this option. Some, but not all, long-term-care insurance policies cover assisted living and other arrangements alternative to nursing home care. There also is some controversy surrounding reimbursement rates for special care units, because of a lack of data to support whether or not a higher cost of care is justified on these units.

Over 1. Nursing aides designated by the acronym NAs and also referred to in this paper as nurse aides, nurse assistants, and nursing assistants and orderlies account for over 40 percent of a home's total FTEs. Registered nurses RNs , on the other hand, make up less than 7 percent of a nursing home's total FTEs and less than 20 percent of a facility's total nursing staff. Of the estimated 1. And yet nothing is more important than the characteristics of the nursing staff in terms of determining the residents' quality of life.

Staff interaction with residents and the nature of the relationship that develops between them is what matters most to residents, far. Proprietary homes averaged 4. Regulations are such that very few nursing homes 5. Because available staff are distributed over a hour period, for every beds the average staffing is 1 RN, who is most likely to be the director of nursing, 1. The median amount of RN time per resident, per day, across all nursing homes in was 12 minutes or less, and nearly 40 percent of nursing homes reported 6 minutes or less of RN time per resident per day Jones et al.

Similarly, the American Nurses Association ANA found staffing ratios of nursing assistants to patients in intermediate-level care facilities to be , whereas the ratio for licensed nurses was ANA, Nursing assistants are the primary care givers in long-term care. Consequently, the care that they provide is an important determinant of the quality of life and quality of care for nursing home residents. The typical NA is a to year-old female; about half are members of a minority group, with low socioeconomic status and a high school education or less.

Typically, they are paid little more than the minimum wage. Nurse vacancy rates are higher in nursing homes than in other practice settings. Despite recent improvements in , 70 percent of state nursing home association executives indicated that vacancy rates in their states had dropped to 10 percent or less McKnight's Long-term Care News , , nurses still find hospitals a more attractive setting in which to work. RN salaries in nursing homes are about 15 percent lower than salaries for hospital RNs Maraldo, While this situation may have changed somewhat, due to greater concerns about hospital costs in recent years, nursing homes continue to compete poorly for RNs because of wages and working conditions.

Unfortunately, caring for the elderly is still not considered prestigious or financially rewarding when compared to other areas of nursing practice. The OBRA 87 regulations contain no staffing standards except that an RN is to be on duty for 8 of the 24 hours each day. Some homes have obtained waivers that permit them to substitute LPNs. Thus, staffing requirements for nursing homes vary from state to state.

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In Iowa, for example, two hours of nursing care hours per patient day are required for certified Medicaid residents. This breaks down to only about five minutes per hour, even though the average resident who is unable to feed him- or herself requires about one hour of assistance for each. If these Medicaid residents who are dependent on receiving help to eat should lose weight continuously over a period of several months, the facility may receive a citation for poor quality care—a real "Catch According to the Select Committee on Aging in the U.

House of Representatives, without changes in staffing regulations, the needs of the elderly will remain largely unmet through the year In their report to the chairman, the committee listed several reasons for a lack of health care personnel trained in geriatrics and gerontology: difficulty recruiting and retaining qualified personnel for direct care in nursing homes, poorly trained workers, little training of family and friend care givers, vague job descriptions, shortages of qualified faculty to teach the needed knowledge and skills to physicians, nurses, and other health professionals, and the lack of appropriate training sites.

Clearly, low salaries for nursing home personnel contribute to recruitment and retention problems and low reimbursement rates affect nursing home providers' interest in paying higher salaries. Nursing home work is often difficult, stressful, frustrating, and labor intensive, especially for NAs, who have the most direct contact with residents. Nursing home staff have to confront aging, disability, and dying.

Much of the care of the elderly is not pleasant, such as caring for urinary and bowel incontinence or dealing with a cognitively impaired elder who is agitated and combative. Combined with low wages, minimal benefits, hard physical work, and the often progressively deteriorating abilities of the residents, the nature of the work for nursing staff is often characterized as tedious, unpleasant, and unrewarding.

Furthermore, because concern for costs is likely to continue while resident acuity increases, the workload of NAs and nurses in nursing homes may very well get heavier. Research related to the actual nature of the work role of NAs documents that the complexity level of most tasks is low suggesting a routinized approach , and that even when NAs carry out direct care tasks, their attention is not always directed toward residents. The highest level of psychosocial quality interaction was found to occur in the process of socializing, an informal component of care, suggesting the need for alternative task structuring and more resident-centered models of care Brannon et al.

Other studies support the notion that staff-. In general, RNs in nursing homes suffer from a lack of prestige within the total health care delivery system. They are not only victims of financial disparity, but they are also subjected to humiliation and professional degradation, and their work role is often tied up exclusively with administrative functions.

While the reasons are many, the lack of respect for nurses who choose to care for the elderly in nursing homes is at least in part because nurses and other health professionals often share the negative attitudes of society toward the elderly Harrington, The work of nursing home personnel is not without rewards, however.

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These rewards are largely intrinsic and evolve from the relationships formed with the elderly residents and the satisfaction gained from feeling that one has contributed to the quality of their lives, if only in a small way. For some, there are also the rewards of personal development that come from learning about aging and the opportunity to gain clinical skills.

Nonetheless, extrinsic rewards for nursing staff remain problematic and this is largely responsible for the frequent turnover of staff and inability to recruit and retain qualified staff. As already mentioned, salaries and other incentives are problematic for all nursing staff in long-term care. One of the major reasons for the dearth of RNs in nursing homes is economic, and retention rates among long-term-care staff have been shown to increase concurrently with increases in average weekly salary.

In they received 88 percent of the typical acute care wage, and by the percentage had dropped to 86 percent. Since , there is some evidence that salaries for some staff in nursing homes may be increasing, although they continue to lag behind salaries in hospitals. The salaries and benefits of nursing assistants, however, provide little incentive and lag behind those for hospital aides and home care aides. Noting that RNs are a critical component of the rural health care delivery system and in some areas the sole providers of care, the Select Committee on Aging reported a shortage of 45, FTE RNs in nonmetropolitan areas of the United States.

According to Kayser-Jones b , often the only nurses willing to work for the low wages offered. Increasing the numbers of minority and disadvantaged persons in the health and allied health professions to care for the underserved, such as the elderly, is an important component of health care reform. Shortages of minority providers may adversely affect access, cost, and quality of care.


At the same time, the background and characteristics of many nursing home staff may adversely affect their job performance Burgio and Scilley, The lives of many nursing assistants, in particular, are beset with personal problems and tragedies that leave them with too few personal resources to respond effectively to residents and that interfere with their ability to provide quality care to the frail, dependent elderly Tellis-Nayak and Tellis-Nayak, In their ethnographic study on quality of care, nursing homes, and nurse aides' cultures, Tellis-Nayak and Tellis-Nayak , p.

Every individual carries a cultural heritage, and older people generally have more ties to their heritage than do many in the younger generations. Elders of particular ethnic or racial minority groups may have customs and beliefs that are important to them, but are no longer remembered or respected by the young. Although it is important for staff to respect and attend to the cultures of Black, Hispanic, Native American, and Asian minorities, it also should be remembered that many Caucasian persons are also members of ethnic groups that have distinct cultures, such as Jews, Poles, or Irish persons Snyder, While it is neither practical nor necessary for staff to share the same ethnicity or cultural heritage as the residents, staff do need to learn about the usual lifestyles and backgrounds of the elders for whom they are caring.

Even staff who share a common culture with residents may find that differences between generations present obstacles to understanding and respect. A clash of beliefs about health and illness and about appropriate remedies and treatments may be disconcerting to both staff and residents. When staff have some knowledge about the usual practices and beliefs of residents, there is a basis for communication that can optimize care and the residents' compliance with recommended treatment.

To promote adjustment in. Problems related to cultural and racial diversity are particularly acute in urban nursing homes, where a majority of staff may belong to minority groups, whereas the residents are predominantly white. Preliminary findings from a study of ethnic and racial conflict between nursing home staff and residents in New York revealed a high prevalence of racially charged verbal abuse and name calling of aides by residents Teresi et al. There is a lack of research and thus an inadequate knowledge base about the long-term health care needs of minority elders and other age groups.

The research that does exist strongly suggests some disparity of service use and inequity of access for ethnic and minority populations, despite increased need Barresi and Stull, While the general growth of the elderly population in the United States is well known, the increase in racial and ethnic elderly populations is less well recognized. Yet the elderly population is increasing faster among ethnic and racial minorities populations Hispanics, American Indians, African Americans, Asians, and Pacific Islanders than among whites, and the total population of ethnic and minority elderly has doubled with each national census since Harper and Alexander, In some parts of the country, these ethnic and minority elderly will soon be the majority among the population aged 65 years and older Cuellar, ; Morioka-Douglas and Yeo, ; Richardson, In , approximately 14 percent of the population 65 and over were persons of color Elders of Color, A significant increase in the population 85 years of age and older and in the number of females is also occurring, and a substantial proportion of these elderly are of racial and ethnic minorities.

Despite having poorer health and less help from relatives than comparison groups of white elders, black elders are less likely to be institutionalized. At comparable rates of frailty, the likelihood of nursing home admission for blacks is less than half that of whites Belgrave and Bradsher, Poverty, geographical isolation, and discrimination are now given more weight in this pattern than the previous characterization of personal preference. Although the Indian Health Service IHS has a statutory responsibility to meet the health needs of American Indians, it tends to define its mission in terms of acute care.

As a result, the rapidly increasing long-term-care needs of the growing numbers of aging tribal members are largely ignored. John points out that an additional problem confronting tribal elders is a policy of age discrimination in resource allocation within the IHS. Specifically, he notes that the IHS concentrates its resources on the health problems of younger tribal members through the Resource Allocation Method, which is based on a calculation of. This strategy virtually ignores health issues for elders over age For example, there are only ten reservation-based nursing homes in the United States, and they currently house residents Manson, A National Indian Council on Aging report indicated that 46 percent of older tribal members are assisted by extended family members to accomplish one or more activities of daily living.

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Data regarding long-term care of the minority population are particularly lacking in respect to Hispanic elderly people, especially given the fact that Hispanics make up about 4 percent of the elderly population in the United States AARP, a and are the fastest growing subgroup of the elderly Lopez-Aqueres et al. What data do exist show that Hispanic populations report greater utilization of informal support systems than of professional health care providers Greene and Monohan, As with Asians and Pacific Islanders in the United States, elder Hispanics face hypertension, tuberculosis, and cancers as their major health concerns.

These elderly are less likely to use formal health care services, including nursing homes, due to lack of knowledge of available services Holmes et al. In a study of nine nursing homes in San Antonio, Texas, Chiodo and colleagues found strong evidence that Mexican American nursing home residents are more cognitively and functionally impaired, after controlling for age and education, than non-Hispanic white residents.

They also were significantly more likely to be funded by Medicaid, and they were more likely to have lived with relatives prior to institutionalization. Major differences between Puerto Rican Hispanics and non-Hispanics admitted to nursing homes were identified in a study by Espino and coworkers The Puerto Rican Hispanics were significantly younger and functionally more impaired, both physically and mentally, than their non-Hispanic counterparts and more similar to chronologically older non-Hispanic nursing home residents. Some research documents the need for nurses to be aware of the implications of ethnicity in caring for the elderly.

In a study of immigrant, Canadian-born, and Anglo-born elderly in long-term-care facilities, Jones and Van Amelsvoort Jones found significant differences in the observed interactions among the groups. Although the elderly as a whole had minimal verbal interaction directed to them during morning and evening care, overall, male residents were spoken to less than female residents, and ethnic females had the least number of commands, the fewest statements, and the least number of questions spoken to them by staff.

Because the numbers of dependent and vulnerable elderly in the population are increasing, abuse and crimes against the elderly will likely continue to occur in proportionate numbers in the future. Elder abuse is identified in the literature as rights violations, physical abuse, material abuse, and psychological abuse Pollick, Rights violations are the denial of the basic rights of the elderly person as defined by the and White House Conferences on Aging Beck and Ferguson, Material abuse is monetary or material theft or misuse DHHS, Physical abuse includes acts of omission or commission that result in physical harm, with omission being the most common Beck and Ferguson, Psychological abuse is behavior that demeans or diminishes the dignity or self-worth of the elderly person Hickey and Douglass, Accurate documentation of elder abuse is problematic because the elderly are often unreliable witnesses or fear retaliation, and because observable physical signs are easily explained as caused by falls and injuries.

Most professionals agree that elder abuse is a common and serious public health problem, with 1 study documenting 60 percent of professionals police officers, social workers, adult protection workers, mental health workers, legal services providers, clergy members, morticians, and coroners reporting that they deal with elder abuse at least once per week Hickey and Douglass, Typically, the abused elder is female, more than 70 years old, physically or mentally impaired or both, and living in the community with an adult child or some family member DHHS, Abuse also occurs, however, in institutional settings.

Research conducted in one bed nonprofit nursing home suggests that the majority of nursing assistants are kind and helpful most of the time, although abuse primarily psychological abuse such as yelling, swearing, and being insulting does occasionally occur. The investigator suggests that the stressful work role of NAs leads to exhaustion and burnout that may precipitate abuse, and argues that mechanisms are needed to help nonprofessional staff deal with their work-related stress Foner, Others Kayser-Jones, have characterized the behavior of NAs as rude, neglectful, uncaring, and sometimes verbally and physically abusive.

Although most nursing homes take care to observe residents' rights, no nursing home can guarantee that every right of every individual will be respected. Problems and conflicts are bound to occur occasionally. Usually complaints are equitably and amicably resolved within the facility. But when a problem cannot be resolved internally, a resident or family member may contact the local office of the long-term-care ombudsman program. Examples of problems and conflict between a family member and staff are feelings of being depreciated or belittled, perceptions that a loved one is not receiving all available services or treatments, concerns about financial matters that are not fully explained or accounted, feelings of discrimination, or concerns that the facility staff does not adequately discuss treatment, transfer, or discharge options.

Physical abuse resulting from poor care, such as skin breakdown, rough handling, or inattention to bowel and urinary elimination needs, is another serious problem that can occur in institutions. This type of physical abuse may be inflicted by health care personnel who are not well qualified Baker, Citing the dearth of research regarding maltreatment of residents of nursing homes, Pillemer provides a theoretical model of maltreatment as the outcome of staff members' and patients' characteristics as these are influenced by aspects of the nursing home environment and by certain factors exogenous to the facility.

As highlighted in the model and supported by a review of the literature, staff who are at more risk for abusive behaviors toward the institutionalized elderly are more likely to be young Penner et al. Department of Justice, ; Straus, , have the least experience Penner et al. More recently, Pillemer and Hudson report an evaluation of a model abuse prevention curriculum for nursing assistants, showing high satisfaction with the program and reduced conflict and abuse of residents.

Cassell also suggests that physicians sometimes abuse their elderly patients when they employ their power in a manner they believe to be in the best interests of the sick. Just as residents can suffer at the hands of staff, nursing staff are also subject to abuse by residents.

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Studies about the incidence of aggressive resident behavior in nursing homes are sparse, but the few available studies suggest that the presence of behavioral problems warrants concern Zimmer et al. Sometimes aggressive resident behaviors are violent and may cause fear in nursing staff as well as harm. Management of aggressive resident behaviors presents difficult care problems for nursing staff.

In a study of nursing home and intermediate care residents in Veterans Administration VA facilities, Winger and colleagues found 9 percent of nursing home and 34 percent of intermediate care residents had no aggressive behaviors, while 84 percent of nursing home residents and 57 percent of intermediate care residents had behaviors that endangered themselves or others. A study by Everitt and coworkers documented that the three most distressing resident behaviors nursing staff encountered were physical abuse, verbal abuse, and wandering.

Lusk , in an exploratory study, found NAs reporting a variety of injuries e. Meddaugh reviewed chart and incident reports to investigate the aggressive behavior of 72 residents in a skilled nursing facility. Twenty-six staff members 27 percent were abused by a resident 1 to 2 times in a 3-month period.

In a study of residents in 4 nursing homes, Ryden and colleagues found that 51 percent of aggressive behavior was physical,. Aggression was correlated with functional dependence, although no category correlated with cognitive impairment. Perhaps most difficult to deal with in nursing homes are the interactions among residents, some of which are positive and encourage friendships, while others are negative and involve violent arguments and even physical fights.

Jones studied residents in 10 intermediate care nursing homes and found that spatial proximity is an important consideration in the analysis of social interaction between residents. Arguments and fights occurred more frequently in fairly restricted spatial arrangements e. The results suggest that in the limited environment of the nursing home both closeness and distance are needed for positive interactions among residents. It is estimated that 22 percent of the elderly long-term-care population live in nursing homes and other facilities, whereas 40 percent or more live at home with a spouse.

The elderly are at higher risk for physical and mental health problems, impaired coping, functional decline, and premature institutionalization than the general population Preston and Mansfield, These risks are even greater for the elderly who live alone and in poverty, particularly women Krout, Medicaid, which is the principal source of funding of health care services for low income persons, finances mostly nursing home care.

DHHS, Nevertheless, there is concern about underuse of nursing home care by some elderly, especially in areas where there are fewer nursing home beds per capita of elderly in the population. In general, rural areas have a higher concentration of the elderly and higher rates of chronic illness and disability. The growing number of older citizens in rural areas is especially pronounced in the Midwest and South. Yet the number of available nursing home beds—whether in traditional nursing homes or alternatives such as in-home care—is less per capita in these areas than in urban areas, and the shortage of RNs is greater in rural areas and in areas where the more impoverished elderly reside Select Committee on Aging, Although Medicaid pays at least some of the costs of care for about 60 percent of nursing home patients, efforts by states to control costs of Medicaid have tended to limit the supply of nursing home beds.

Further, the lack of Medicare reimbursement and the spend-down requirements to qualify for Medic-. As mentioned earlier, the population of older adults with complex and chronic conditions that require long-term care is growing. In there were about 1. Current demographic predictions suggest that although the proportion of the U. With a stable population, these increases in proportion reflect the increase in the absolute numbers of elderly persons, particularly those 85 and older, who will increase in number from about , in to an estimated 1.

Over the next several decades, the proportion of nursing residents who are "old-old" i. Recent estimates indicate that one-half of the women and almost one-third of the men who turned 65 in will require nursing home care during their life. By the year , an estimated 76 percent of the elderly are expected to be completely independent, but 24 percent of the elderly—about 7 million elderly persons—are projected to have some impairment that requires them to seek assistance with one or more activities of daily living Scanlon, ; Kane and Kane, The number of dependent elders is expected to grow as the proportion of elderly in the population, especially those over age 75, increases Griffin et al.

Dependencies for assistance range from instrumental activities of daily living IADL , such as cooking, shopping, and cleaning, to personal care activities of daily living ADL , such as toileting, dressing, bathing, transfer and ambulation, and eating. Of the 7 million elderly needing long-term care by the year , 1. Further, as a result of the aging population and increasing life expectancy, by the year the number of elderly residents in nursing homes could nearly double Kemper and Murtaugh, By , the elderly will comprise 20 percent of the population and use 30 percent of health care resources Select Committee on Aging, The majority of residents in nursing homes will be 80 years and older, functionally depen-.

Because of continued short hospital stays for acute illnesses and increased use of home care services where possible, residents in nursing homes will tend to be sicker and more acute illnesses will be treated in the nursing home. At the same time, alternative settings, such as assisted living and group home facilities, will be more available and will house more of the younger elderly with fewer or less severe impairments O'Connor, More emphasis in these facilities will be placed on rehabilitation to maintain and improve function.

Convalescent nursing homes are also expected to be more prevalent, with many elderly discharged to their own home after a short stay for recovery and rehabilitation. Nursing homes will also include greater numbers of residents with AIDS, more residents with infections like methacycline-resistant Staphylococcus aureus and tuberculosis, elderly who are developmentally disabled, residents requiring rehabilitation, and hospice residents. Special units devoted to the care of residents with these conditions, as well as residents on ventilators and with pressure sores, are expected to increase.

Although it is positive that more alternatives to nursing homes will be available for the elderly, the downside is that the majority, if not all, of the residents of nursing homes will require more complex and intensive nursing care, and most will be highly functionally debilitated both cognitively and physically. Logically, this changing case-mix has clear implications for the types and numbers of staff that will be required to deliver quality care. More professional nursing staff registered nurses with gerontological training and greater use of gerontological nurse practitioners will be needed, both to plan and provide care and to direct and supervise the care provided by assisting staff.

The nature of the work with mostly "old old," highly debilitated residents will provide quality-of-care challenges for assisting staff that they will not be able to meet without professional leadership and direction, and it will exacerbate stress, burnout, and turnover problems that are already of great concern.

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As home- and community-based long-term-care options e. More than 50 percent of nursing home admissions currently come from hospitals, with most needing care for unstable medical conditions. According to a report on a subacute care demonstration project in Illinois McKnight's Long-term Care News , , subacute care includes physician supervision and RN care and physiological monitoring on a continuous basis.

Rules related to quality assessment and quality improvement, personnel requirements, and admissions practices have been set forth by the Joint Commission on Accreditation of Healthcare Organizations JCAHO , which has recently incorporated subacute care into its survey process. Increased staff levels will be necessary to accommodate patients receiving subacute medical, nursing, and rehabilitation services. Outcomes, physical plant, and physician credentials are three major areas addressed in JCAHO accreditation standards for subacute units Stahl, It is noted that RN credentials are not included, a curiosity since RNs will obviously play a large role in the care of residents in subacute units in nursing homes.

A further concern is that the medical focus will continue to compromise implementation of a social-behavioral model of care in nursing homes. Special care units SCU emerged as an important environmental intervention for care of persons with dementia in the s. Today more than 1 in 10 nursing homes has a special unit or program for people with dementia, with more than 1, SCUs providing in excess of 50, special care beds.

Data indicate that the number of SCUs is continuing to grow rapidly, with more than 2, units projected to be in operation by NIA, Although there is much diversity among SCUs, most incorporate some type of physical modification, including security measures to limit egress, specialized activity programming for residents, and special training for staff, who are often permanently assigned to the unit. There are several reports of studies to evaluate the effects of SCUs; however, most have not employed designs with sufficient control to rule out competing explanations Greene et al.

Experimental research by Maas and Buckwalter is one exception. Analysis revealed no significant changes in cognitive or functional abilities over time and no significant differences in these abilities between Alzheimer's disease patients on the SCU and on traditional integrated nursing home units Swanson et al.

Patients on the special unit were restrained less than those living on traditional units, but the SCU patients fell significantly more, on the average. The total number of medications for each patient was not significantly different for SCU versus traditional unit patients, and the number per patient did not increase over the 1-year study period.

A multicenter collaborative initiative, funded by the National Institute on Aging and designed to explore the effectiveness of SCUs, evaluate specific interventions and family involvement in care, and compare SCU outcomes to those of traditional nursing home care, is currently under way. The projected demand for nursing home care has sparked debate over costs and the adequacy of homes to deliver quality care. The anticipated need for qualified care givers in nursing homes is expected to increase anywhere from two- to fivefold by the middle of the next century DHHS, Projections of the number of FTE registered nurses needed to supervise care by the year range from , to slightly over 1 million NIA, The House of Representatives Select Committee on Aging forecast that by , at least 36, geriatricians and 1.

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According to the Select Committee's estimate, , RNs will be needed in nursing homes compared to 94, in Current RN-to-resident ratios for nursing homes are estimated to be 6. In addition, , NAs will be needed in nursing homes compared to , in , and , licensed practical nurses LPN compared to , in Select Committee on Aging, Although estimates of current and projected staffing vary according to time frame and perspectives on the appropriate staff mix in nursing homes, it is apparent that the demand for nursing staff in nursing homes is rising dramatically. The rising demand may influence recommendations for staffing numbers and staff-mix in nursing homes, despite a lack of research evidence directly linking quality and staffing.

There is no doubt that OBRA has done a great deal to improve the quality of care in nursing homes by placing new emphasis on outcomes evaluation, staff training, residents' rights and quality of life, and the decreased use of restraints and psychoactive drugs. In our view, the OBRA regulations are minimal and do not go far enough in requiring hour RN coverage with specific numbers of assisting staff for a specific number of residents to assure quality of care and reasonable work expectations for staff.

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 Institute of Medicine's Committee on Nursing Home Regulation recommended that "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.

Despite such recommendations, the nursing home industry has sought waivers even of OBRA's minimal increases in staffing standards Francese and Mohler, The industry cites a shortage of RNs and inadequate reimbursement to pay their salaries as reasons for not being able to meet the OBRA staffing standards. Thus the nation's ability to meet the future demand for long-term care will continue to be affected by government reimbursement policies that are not commensurate with government regulations regarding the quality of care.

This section undertakes a review of the literature that investigates the quality of care provided in long-term-care facilities and examines linkages between quality of care and various aspects of nurse staffing. Following an initial discussion of definitions of quality and how it is measured, we discuss the relationship between cost and quality of care. Studies are then presented that focus on aspects of staffing staff attitudes, level of training, level of stress and turnover rates, number of staff and staff mix and that consider the effect of the variables on quality of care.

Finally, we review research that examines the relationship between quality of care and environmental factors such as reimbursement policies, type of facilities, and management systems or organizational climate. Few concepts have been more elusive, controversial, or politically volatile than nursing home quality of care.

Perhaps this is because as individuals we all fear functional impairment, loss of independence, and impoverishment, but as citizens we do not have the will to provide the financing for quality of care in nursing homes. Quality of care in nursing homes is a complex concept confounded by regulations and debates about what should be measured to assess quality, case-mix, facility characteristics, and methods of measurement Mezey, ; Mezey and Lynaugh, Moreover, quality of care has been defined both as an input measure and as an outcome Kruzich et al.

But perhaps most confounding has been the continued reliance upon a medical model in defining standards of care and reimbursement formulas.

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  4. Quality in long-term care requires different strategies than in acute care. In long-term care the focus is on replacing the patient role with a self-care role, emphasizing the individual's abilities to function with remaining abilities despite chronic disease, impairment, or both. Nursing homes are "nursing" homes so, clearly, quality of care is dependent upon the quality of nursing. Yet professional RNs are so scant in nursing homes as to be almost a novelty Maraldo, Prior to OBRA 87, quality of care in nursing homes was largely evaluated and regulated according to structure and process standards rather than the achievement of patient outcomes.

    Traditional reliance on structural measures failed to capture the essence of nursing home quality Braun, , although Stein and colleagues found that resident perceptions of quality and level of satisfaction were strongly related to objective surveyor ratings of nursing home quality.

    In Kurowski and Shaughnessey's review of studies comparing quality of homes with regulator surveys, many aspects of quality were not sensitive to the surveys and adding observation to surveys did not adequately measure quality Fackelmann, Davis reviewed a number of studies that have examined macro-organizational and structural variables and quality and noted the paucity of empirical evidence to support these linkages.

    The Omnibus Budget Reconciliation Act of provided a starting point for a new definition of quality in long-term care and focused measurement of quality on patient outcomes Wilging, According to OBRA, a nursing home's purpose is to "bring each resident to the highest practicable level of mental, physical, and psychosocial well-being, and to do so in an environment that emphasizes resident's rights" Wilging, , p.

    Quality care begins with a standardized, comprehensive patient assessment coordinated by an RN, which requires that specific attention be given to activities of daily living, vision and hearing, pressure sores, urinary incontinence, range of motion, psychosocial functioning, use of nasogastric tubes, accidents, nutrition, hydration, antipsychotic and other drug use, and special services such as respiratory therapy.

    Bowel elimination was ignored as an outcome to be monitored, but has been added in version 2. The OBRA legislation proved to be the impetus for improving the quality of care in nursing homes. The requirement that specific fields be included in a minimum data set MDS on all residents in nursing homes provides a valuable source of data for evaluating quality on the basis of resident outcomes Zimmerman, From the data on resident outcomes included in the MDS, quality indicators have been proposed and are being tested for how well they measure quality for aggregates of residents in nursing homes Rantz and Miller, The "highest practicable level of functioning," however, is in reality defined by what is fiscally appropriate within each facility.

    Whether or not adequate resources are available to provide quality care is still an issue, and many would agree that resources are often not adequate. For example, the study conducted by the Institute of Medicine's Committee on Nursing Home Regulation supported higher nursing staff standards as a major means for assuring quality of care in nursing homes, along with new staffing, training, and registry requirements for nursing staff IOM, Unfortunately, the goal of requiring hour RN.

    Although OBRA increased staffing requirements, the facts are that nursing assistants make up 85 percent of nursing staff in nursing homes and provide the majority of direct care to residents, with residents receiving on average only 12 minutes per day of care from RNs Maraldo, As noted earlier, the issue of staff-to-resident ratios is also of concern. In acute care, there are an estimated 98 RNs for every patients, while in nursing homes there are 5. This marked discrepancy is not likely due to a true corresponding difference in the needs of patients for nursing care in the two settings, but is rather due to how "highest practicable" is being defined by economic and political realities.

    The concept of quality in the practice setting has, to date, included only limited attention to outcome assessments and public input DHHS, Traditional paradigms of quality thus need redefinition to assure an excellence in health care that is responsive to the changing needs of the public. The movement to continuous quality improvement CQI is seen as one way of focusing on processes and systems, rather than individual efforts, in quality management applications DHHS, When residents are asked what constitutes quality of care and what factors are most important in creating a good environment, they emphasize kindness, consideration, friendliness, and empathetic listening on the part of staff, suggesting that staff attitudes have a major impact on resident quality of life Goodwin and Trocchio, Although families continue to be involved in care following placement of their loved one in a nursing facility, relatively little is known about the relationships among families and nursing home staff, especially from the perspective of family members Duncan and Morgan, What research has been conducted in this area indicates that families equate good quality nursing home care with care that is affectively appropriate, emotionally sensitive, respectful, and professional, and that emphasizes a personal relationship with the resident.

    Families tend to base their evaluations of care as much on social and emotional factors as they do technical competence in performing care tasks Bowers, ; Duncan and Morgan, , whereas staff often give priority to the smooth functioning of the organization. What this means is that nurse aides, in particular, often get caught between the desires of the organization and those of family members Duncan and Morgan,