Nursing Homes

In 1997, it was estimated there were approximately 1.4 million full-time and part-time employees in nursing homes. The recruitment and retention of these employees, although a significant issue for all businesses today, pose some rather unique challenges for nursing-facility providers. The challenge of retention is critical in a nursing-facility environment because of the direct impact it has on quality-of-care issues. The administrative team, working with other staff in a facility, creates the culture of quality care. The ability to create and maintain a culture of quality is often hindered by high turnover of staff in many facilities. Singh and Schwab (1998) report that about 40 percent of nursing home administrators turn over each year, and the American Health Care Association (AHCA) reported in 1997 that the turnover rate for RNs and LPNs was 51 percent and that nurse's aides had a turnover rate of 93 percent. Registered nurses account for only 15 percent of the average nursing staff, while certified nurse's aides account for nearly 66 percent of staff. A number of factors contribute to staff turnover, including job stress, limited career opportunities, pay, and organizational culture. When looking at the clinical staff, the area that receives the most attention is pay. Based on 1997 data, the average RN was paid $16.88 per hour, LPN wages averaged $12.88, and nursing aide wages averaged $7.44. When these relatively low hourly rates are combined with a minimal benefit package, a strong economy, and the demands associated with caring for frail, medically complex persons, the challenge to retain quality employees can be easily appreciated.

The need to improve staffing standards and levels has received increased attention. In 1997, the staff-to-resident ratio for all direct-care staff was 89 per 100 residents and 59 nurse's aides per 100 residents. Certified nurse's aides spend the most time with residents, providing a significant portion of direct care, and yet they are often not well prepared to provide the level of care required by residents with increasingly complex medical problems. Based on the Medicare time studies that used the Online Survey, Certification, and Reporting (OSCAR) system, staffing hours for nurses averaged 3.5 hours per resident day (24 hours) for all nursing facilities in 1998. Registered nurses were found to spend 0.74 hours per resident day, LPNs spent 0.69 hours per resident-day, and nurse's aides averaged 2.09 hours. Because of the wide variation in resident care needs these numbers vary significantly across facilities. In contrast to the OSCAR finding of 3.5 hours per resident-day, a CMS time study came up with 4.17 hours, and a recently convened expert panel found the average to be 4.55 hours.

The recently released Institute of Medicine study on improving the quality of long-term care adds its support to this issue by recommending that CMS not only require RN presence twenty-four hours per day, but also that minimum staffing levels for direct care be developed.

Finally, the increasing role of the medical director has contributed to improving the quality of care. Each facility is required to have a medical director, who provides care to those residents who do not have a primary care provider. The medical director also plays a critical role in shaping clinical policies and procedures. The voluntary certification of physicians as Certified Medical Directors offered through the American Medical Directors Association has assisted physicians to better understand not only their clinical role within long-term care, but also to have a better appreciation of how to more effectively work within a nursing facility and as an active member of the administrative team.