Professor and RN, Charlene Harrington discusses with host Dr. Bill Rutenberg the recently launched UCSF demonstration project to design and test nursing interventions to improve quality of care in nursing homes. A focus of the study is to "refine a practice model to transform the nursing home care, based on peer-reviewed research into what works and what does not." Another goal of the study is to "translate the findings from the current research into practical changes on a national scale."
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UCSF Project to Improve Nursing Home Quality
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Host: DR. BILL RUTENBERG
Guest: DR. CHARLENE HARRINGTON
ReachMD XM 157 presents a special series Insights In Future Medicine. When you are ready for the home, will the home be ready for you? You are listening to a special program on Nursing Homes, what's wrong and how to fix them on ReachMD XM 157, The Channel for Medical Professionals. I am Dr. Bill Rutenberg your host and with me today is Dr. Charlene Harrington. Dr. Harrington is Professor of Sociology and Nursing in the Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco. She is the Associate Director of the John A. Hartford Center for Geriatric Nursing Excellence and Director of the Doctorate Program in Nursing and Health Policy at UCSF. Today, we are discussing the just launched UCSF Nursing School Demonstration Project to design and test nursing interventions to improve quality of care in nursing homes. Welcome Dr. Harrington and thank you so much for taking the time to join us for this special program.
DR. CHARLENE HARRINGTON:
You are welcome.
DR. BILL RUTENBERG:
What are the big problems with nursing homes today that led you to organize this project?
Dr. CHARLENE HARRINGTON:
Well, the single biggest problem with nursing homes is the inadequate levels of staffing, nurse staffing in nursing home. And we are finding that only 5% of the nursing homes in the country have the staffing levels that research shows that they should have. So, this is the major concern, is how to get nursing (01:30) homes to increase the number of nurses and particularly the number of RNs in nursing homes, because the research clearly shows that having a higher number of RNs makes an important difference in improving quality.
DR. BILL RUTENBERG:
I have noticed in the hospitals and also in some of the nursing homes, where I visited friends, relatives primarily the parents that many of the nurses are coming from other countries. Is that a problem or is that part of the solution?
CHARLENE HARRINGTON:
Well, it's certainly been part of the solution so far because most of the states are not producing enough nurses to meet the demand. So, I think we are fortunate to have the nurses we have, but we are hoping that states will recognize the importance of making sure they are educating enough nurses within the state to care for patients in hospitals, nursing homes, and other settings.
DR. BILL RUTENBERG:
Do you have some thoughts on how to increase the number of people entering nursing programs? In fact, I have seen nursing schools closing and can you imagine a way of increasing the number of people going into nursing?
DR. CHARLENE HARRINGTON:
Well, the problem with nursing right now is the working conditions that they face in hospitals and nursing homes. They are very understaffed in most of these facilities and so we have nurses that have dropped out of nursing and (03:00) so it's a retention problem. But it's hard to recruit new nurses for the future, if they think their working conditions are not going to be ideal. So, we really think that the major focus right now needs to be on improving working conditions at the workplace and having greater flexibility for hours and the type of work that nurses do. And of course, we are do need more schools for nursing in some states like California are putting in more money to increase the number of slots within schools of nursing and we have actually opened or planning to open two new schools of nursing in the state.
DR. BILL RUTENBERG:
No, that's great. I am the nursing home Owner-Director and you come to visit me. From your experience, what would you say are two or three things I need to do to make it a better place to work?
DR. CHARLENE HARRINGTON:
In terms of the work environment?
DR. BILL RUTENBERG:
Yes.
DR. CHARLENE HARRINGTON:
Well, the single biggest factor is the workload and we are finding that nursing assistants frequently have 12 to 15 patients during the day and the evening shift and they really should only have 7 according to our research because they can't get the work done for that many patients, in terms of how the people eat, dressing, bathing, toileting, turning, walking and all the essential things that need to go on in a nursing home. (04:30) For RNs, they frequently have 40 patients and that's really unattainable.
DR. BILL RUTENBERG:
You said 40?
DR. CHARLENE HARRINGTON:
40, in terms of trying to get medications and treatments.
DR. BILL RUTENBERG:
That's impossible.
DR. CHARLENE HARRINGTON:
It's impossible and so they leave, so we need to get the RN ratios down to around 20 to 25 at the most per RN. And the big problem is that nursing facilities are trying to save money and many are trying to make profits and then primary way they do that is by cutting the staffing and then this increases the turnover because the nurses won't stay, if their workloads are too heavy. That's the major problem right now.
DR. BILL RUTENBERG:
Those are one of the things I was going to ask; I mean nursing homes are multibillion dollar industry. Why they are finding it so difficult to retain nurses? Is it just because they are more interested in profits than patient care?
DR. CHARLENE HARRINGTON:
Yeah 75% are for profit and over 50% are chain operative facilities. Some of them are making up to 25% profit, which is just excessive and the only way to do that is to cut your staffing down to bare bones. And that's why we think that probably 25% to 30% of nursing homes have completely inadequate staffing and only 5% have adequate staffing and most of the ones that have good staffing (06:00) are non-profits and they are very committed to having enough staff and they have good wages and benefits for employees.
DR. BILL RUTENBERG:
I would like to pause for a moment to welcome those who are just joining us. You are listening to ReachMD XM 157, The Channel for Medical Professionals. I am Dr. Bill Rutenberg your host and I am speaking with Dr. Charlene Harrington, Professor of Sociology and Nursing at the University of California, San Francisco. We are discussing the UCSF School of Nursing Demonstration Project to improve quality of care in nursing homes.
The problem with staffing, is this something that regulation can help? Would your study do you think lead to new regulations in terms of the requirements for staffing levels?
DR. CHARLENE HARRINGTON:
We are urging states to implement new regulations to increase their requirements up to a total of 4.1 hours per patient per day and a 0.75 RN hours per patient per day. That will I guess reduce the number of nurses per patient and allow for better quality. So, we are hoping that states will implement these staffing standards.
DR. BILL RUTENBERG:
One of the other goals of the study is to define or refine a practice model that will transform nursing home care based on peer reviewed research into what works and what does not. In addition to staffing, are there other deficiencies that research has indicated that need to be introduced into nursing homes?
DR. CHARLENE HARRINGTON:
(07:30) Yes, we think that one of the most important areas is to improve the nursing or the RN leadership in nursing homes. So, we are encouraging training and mentoring models that will improve the leadership and the supervision activities of the RNs. So, we are designing a model that would address those issues because it's not just staffing, it's how you deploy the staff. And many nursing homes have a very high article model of work and this is problematic for the nursing assistance because they don't have good working relationships with the RNs in some cases. So, we want to improve those working relationships and really see if we can just improve the productivity and the coordination and the continuity of care that way.
DR. BILL RUTENBERG:
Would you define specific roles for RNs and nursing assistances or any thoughts on how to do this thing? Communication is always the big problem.
DR. CHARLENE HARRINGTON:
Primarily, the issue of communication and how to mentor the staff, how to give them good feedbacks so that they can be more confident in their job, we also are recommending the use of Advanced Practice Nurses to help with the quality assurance activities and the education and training of staff in nursing homes.
DR. BILL RUTENBERG:
Will you be enlisting nursing homes (09:00) to participate in the study to sort of service models or if you want to say laboratories where this is going to take place?
DR. CHARLENE HARRINGTON:
Yes, we are looking for nursing homes that are willing to try out this approach and so we are going to be recruiting nursing homes at 5 different sites around the country this year and then hoping to start our demonstration project after July.
DR. BILL RUTENBERG:
So, it is going to be a multicenter project?
DR. CHARLENE HARRINGTON:
Yes, it's multisite project and we will have some common elements across all the sites and then there maybe some extra activities that we try out at different sites.
DR. BILL RUTENBERG:
Will the nursing homes be compensated for participating?
DR. CHARLENE HARRINGTON:
Well, they won't be compensated for increasing staffing, but we hope that we will have funds that will help pay for these Advanced Practice Nurses and some of the enhancements and then leadership training that we want to introduce.
DR. BILL RUTENBERG:
Will there be any input to the study from patients in the nursing homes and staff currently employed at the nursing homes?
DR. CHARLENE HARRINGTON:
Oh definitely, this has to be a very interactive model and the projects will have to be negotiated at each site because each site will have different needs and we need to address the needs of particular nursing homes.
DR. BILL RUTENBERG:
Translational Research is a big term today of talking to people at the CDC Diabetes Translation, (10:30) on MRSA in translating what we have learned in the research laboratories into practical day-to-day use. One of your goals is to translate the findings from the current research into practical changes. What kind of practical changes are needed in addition to the staffing and the leadership? Are the staffing issues in terms of other ancillary personal, whether it would be respiratory therapy, or dieticians, discharged planning? I mean there are so many facets to taking care of a patient in nursing home. And I know you can't tackle them all, but you know if you are going to give us the five goals of the current research project. We talked about staffing and leadership; are there other ones that you are going to focus on?
DR. CHARLENE HARRINGTON:
Well, I think all the ones you mentioned are important but we also want to focus on continuity of care and consistent assignment because we know that improves the quality and also in may be the use of electronic documentation this is a new area that has not been used very much in nursing homes and so there are some studies that show this makes improvement in quality outcomes. So, there aren't so many aspects, scenarios that need to be improved, so we are trying to look at as many of them as we can.
DR. BILL RUTENBERG:
Will separate or new software have to be developed for nursing home medical records or can you pretty well adapt what's being used in the hospitals?
DR. CHARLENE HARRINGTON:
(12:00) No, we wouldn't be using what's in hospitals. There are some projects already, one at the Agency for Healthcare Research and Quality is using and that's primarily for nursing documentation of nursing activities.
DR. BILL RUTENBERG:
I would like to thank you for speaking with us today Dr. Harrington and for being our guest. We have been discussing making nursing homes a better place to live. I am Dr. Bill Rutenberg. I hope you have enjoyed listening to this program on the future of nursing homes on ReachMD XM 157, The Channel for Medical Professionals. We welcome your comments and questions. Please visit us at www.reachmd.com and take advantage of our new on-demand and podcast features, which gives you access to our entire program library. Thanks for listening. I wish you a good day and good health.
Thank you for listening to a special series Insights in Future Medicine on ReachMD XM 157, The Channel for Medical Professionals.
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Overview
Professor and RN, Charlene Harrington discusses with host Dr. Bill Rutenberg the recently launched UCSF demonstration project to design and test nursing interventions to improve quality of care in nursing homes. A focus of the study is to "refine a practice model to transform the nursing home care, based on peer-reviewed research into what works and what does not." Another goal of the study is to "translate the findings from the current research into practical changes on a national scale."
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