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Consensus Statement of the Campaign for Quality Care

Widespread Substandard Staffing In America's Nursing Homes Needs Immediate Action: Over 800,000 Nursing Home Residents Affected - July 27, 2000

NCCNHR Calls for Action to Correct Widespread Substandard Staffing in Nursing Homes - July 23, 2000

Consensus Statement of the Campaign for Quality Care

This statement is endorsed by the following organizations (as of March 21, 2001):

Alliance for Retired Americans

Alzheimer’s Association

American Association of Homes and Services for the Aging

American Dietetic Association

American Federation of State, County and Municipal Employees

American Health Care Association

American Nurses Association

American Occupational Therapy Association

American Society of Consultant Pharmacists

The Catholic Health Association of the United States

Center for Medicare Advocacy, Inc.

Food and Allied Service Trades, AFL/CIO

Institute for Palliative & Hospice Training, Inc.

John A. Hartford Institute for Geriatric Nursing

National Association for the Support of Long Term Care

National Association of Area Agencies on Aging

National Association of Directors of Nursing Administration in Long Term Care

National Association of State Long Term Care Ombudsman Programs

National Citizens’ Coalition for Nursing Home Reform

National Committee to Preserve Social Security and Medicare National Senior Citizens Law Center Paraprofessional Healthcare Institute Service Employees International Union United Food and Commercial Workers Union

Nursing homes across the country continue to experience a staffing crisis that can jeopardize quality of care and life for residents. This crisis includes insufficient numbers of staff, including certified nursing assistants (CNAs), licensed practical or vocational nurses (LPN/LVNs) and registered nurses (RNs). The reasons for the staffing crisis are complex and multi-factorial. Factors that contribute to the staffing crisis include issues related to:

· recruiting and hiring of qualified job applicants

· retention

· payment systems

· wages and benefits

· education, training and supervision

· workload

· philosophy of the organization/staff empowerment

· workplace safety

· opportunities for advancement

· external issues such as transportation and child care

· public perception

Recruiting and Hiring of Qualified Job Applicants

Nursing homes have traditionally attracted staff who identify themselves as caregivers and as people who "want to help others.” Unfortunately, factors such as workloads, wages and a public image of work in nursing facilities can make recruitment difficult. This is exacerbated in times of high employment.

Retention

Retention of qualified nursing personnel is a particular and industry-wide problem. Although turnover rates vary by region, various provider and other surveys indicate CNA turnover to be between 49 percent and 143 percent. The most frequent reasons for leaving a job are unrealistic workload and low wages. Lack of supervision because of shortages of licensed nurses also increases frustration and job dissatisfaction. Many employees receive their CNA training to work in nursing facilities, and once certified, choose to work instead in acute care settings that can pay higher wages than nursing homes. These same surveys indicate the turnover rate for RNs ranges from 28 percent to 59 percent and for LPN/LVNs turnover ranges from 27 percent to 61 percent per year. The result can be a chronic lack of staff or dependence on agency personnel, an alternative that is costly in financial and human terms.

Payment Systems

Public payment systems finance the cost of care for nearly 80% of all nursing home residents through government payers, including Medicaid (67.6%) and Medicare (9%). As both of these programs move from a cost-based to a prospective payment system, the policymakers’ intent is to control expenditures of public funds. Reimbursement levels through these programs, based on accurate resident and staffing data and fiscal accountability for use of reimbursement, must be adequate to employ and support enough staff and services to meet resident needs. Care for frail elderly and seriously ill persons is labor intensive and costly. Reimbursement levels are a significant determinant of providers’ ability to deliver optimal quality care.

Wages and Benefits

Inadequate pay for nursing staff in nursing homes contributes to the staffing crisis. Due to differences in payment systems and other factors, RNs, LPNs and CNAs are usually paid appreciably less in nursing homes than they are in hospitals. Many CNAs do not have retirement benefits and many who are offered health care benefits cannot afford to accept them because of the cost of deductibles, co-payments, and premiums. Wages and benefits for all staff must be fair and competitive with those in hospital and other health care settings.

Education, Training and Supervision

Additional training would better prepare CNAs to care for the increasingly complex needs of residents living in nursing homes. For the protection of residents, CNAs and LPNs legally must work under the supervision of RNs. However, because more registered nurses are needed, many CNAs and LPNs do not benefit from sufficient hands-on advice and training. RNs also need appropriate supervision and specialized training to address the unique needs of nursing home residents.

Workload

In many nursing homes, CNAs, who provide most of the personal care, and licensed nurses, who also provide direct care, are assigned to more residents than they can properly care for. In situations where unrealistic workloads exist, resident needs are often unmet, raising the risk of harmful and costly complications. This frustrates those who feel responsible for the care of residents. The responsibilities of licensed staff have expanded as the percentage of residents with complex mental, physical, and psychosocial care needs has increased. The workloads for licensed nurses have also grown due to an increase in mandatory record keeping and duplicative documentation that removes them from the frontlines. Reasonable workloads are a necessary condition for quality care.

Philosophy of the Organization/Staff Empowerment

While increasing numbers of homes are experimenting with and implementing new approaches that consider both staff needs and resident preferences/life-habits, work schedules and routines are often assigned without consultation or participation of staff or consideration of residents’ individualized needs. Staff schedules that conflict with outside responsibilities can cause stress and job dissatisfaction. Additionally, the structure of authority and responsibility in nursing homes tends to separate administrative nurses from staff nurses, and unit nurses from nursing assistants, and nursing assistants from residents. This can affect a team approach to care planning and delivery.

Workplace Safety

Adequate staffing is an essential component to workplace safety. Insufficient numbers of staff or a shortage of appropriately trained staff can contribute to increased risk for staff injuries and illness. Too few staff leads to increased safety risks that can result in injuries to workers who then can suffer from the pain and long-lasting effects of back and other injuries. Additionally, all staff are at risk of exposure to blood-borne pathogens and antibiotic resistant organisms.

Opportunities For Advancement

While some nursing homes provide opportunities for CNAs to earn increased pay for increased responsibility, for many CNAs, the only options for advancement would require leaving nursing home work or obtaining the education to become a licensed or registered nurse. The latter is an option that many CNAs do not have the time, money or interest to pursue. Incentives and recognition should be available for the many CNAs who choose to remain in their careers. Historically, licensed nurses have had minimal education in gerontology or unit management – knowledge that is needed for promotion to higher-level positions such as Director of Nursing. Opportunities for LPNs to pursue RN training and for RNs to pursue continuing education and advanced education degrees can also be prohibitive in time and cost.

External Issues Such As Transportation and Child Care

CNAs, licensed nurses, and other personnel frequently face obstacles in affording the costs associated with employment. For example, in many areas of the country the high cost and inaccessibility of public transportation make it difficult for nursing home staff to apply for, and remain, on the job. Even for workers who have their own vehicles, parking fees, fuel, and maintenance expenses may be difficult to meet.

Public Perception

A negative public perception of nursing home care and caregiving has also been cited as a contributing factor to the staffing crisis. There are many committed nursing home employees who deliver compassionate and competent care to residents.

Conclusion

The staffing crisis in nursing homes has developed and worsened over time, influenced by social, economic, and demographic factors. Political factors and management philosophies have also contributed to the staffing crisis. However, the undersigned organizations believe that the crisis can be alleviated or resolved by changes in our public policies, professional practices, and education. We are committed to working together to address the problems and find solutions. We call upon organizations representing all of those who are affected – consumers and providers of care, the health professions, labor, and policymakers – to join our effort.

News Release

***To read the full HCFA report, click here!***

Washington, DC—The National Citizens’ Coalition for Nursing Home Reform (NCCNHR), a national consumer organization devoted to nursing home issues for 25 years, is calling on Congress to react boldly to recent information from a HCFA study that indicates 54 percent of nursing homes subject residents to harm due to inadequate staffing. The study is the topic of a Senate Special Committee on Aging hearing July 27, 2000. According to executive director Randi Goldstein, "residents, family members, advocates, ombudsmen, and thousands of nursing home workers need support and are ready for Congress to legislate changes to increase staffing standards."

In 1997, NCCNHR identified the seriousness of the nurse staffing issue for the Senate Special Committee on Aging, other Congressional leaders, and the Health Care Financing Administration when it helped the Committee organize a forum to address malnutrition and dehydration suffered by residents. Consumers were clear then, as they had been for many years, that serious nursing home problems can only be alleviated if staffing issues are taken seriously and corrected. Last year, at another Senate forum proposed by NCCNHR, Senator Grassley heard strong messages from NCCNHR member groups about the severe staff shortages in nursing homes in their states.

Consumers are woefully tired of policy-makers, including politically powerful nursing home leaders, who ignore the obvious - residents will suffer and deteriorate and even die prematurely if they do not receive the basic care so clearly prescribed in our national nursing home reform law. The 1987 law has never been fully implemented or enforced. Low staffing is only cited for 4.6% of homes in spite of the overwhelming evidence in the HCFA report.

Senator Grassley and HCFA’s Administrator Nancy Ann DeParle are to be praised for paying serious attention to consumer concerns. However, action has been stymied with the admonition that action must be delayed until the long-awaited nurse staffing study was concluded. Goldstein advises that NCCNHR plans a national effort to alert consumers to the study findings and to gain support for legislative changes that will increase staffing and improve care for nursing home residents. Low staffing affects every aspect of daily care for residents and workers alike.

This is not a new issue! Low staffing has been continually brought to the attention of Congress since the late 1960’s. NCCNHR is calling on Congress and the nursing home industry to publicly recognize today’s serious staffing problems and to support changes that will actually make a difference for residents. The history of this issue is long and deep. A band-aid approach, such as proposed by the industry through single task workers, will simply not work.

For these reasons, NCCNHR, its members and supporters, are proposing a national minimum number of required nursing hours per resident per day. NCCNHR’s proposal, endorsed by many experts in this field, calls for 1:5 direct care workers for the day shift; 1:10 for the evening shift; and, 1:15 at nights, with adequate registered nurse (RN) and licensed practical nurse (LPN) supervision. Proposed ratios would be higher for facilities with residents who need more care.

NCCNHR contends that the public should not have to grapple with tired excuses given by the industry for not achieving the staffing needed to provide good care to residents. Staffing shortages cannot simply be attributed to lack of dollars to provide the care, or to a low unemployment rate. Even homes which have filed for bankruptcy are staying in the business – just reconfiguring their structure and/or shifting leadership - taking full advantage of the protections and bail-out that bankruptcy laws allow.

When owners are given increased reimbursement, there is no evidence that they employ more staff or raise salaries, unless accountability measures are specifically built into law. Thousands of residents develop preventable pressure sores, contractures, incontinence, malnutrition, dehydration and pneumonia, infectious diseases, and other painful conditions. The cost in human suffering cannot be counted, but must be admitted – and ended. As taxpayers, we spend literally billions of dollars, largely from Medicare funds, treating conditions, which should never have occurred in the first place. The costs are staggering, but they only begin to tell the story. Sarah Burger, NCCNHR’s Director of Special Projects states, "Money should be spent on staffing to prevent harm, not to fix harm." (See enclosure or website for information on "The High Cost of Poor Care.")

Staffing shortages in nursing homes cannot merely be attributed to a "good" economy. "In fact," stated Elma Holder, NCCNHR’s founder, "when people address the nurse staffing issue, ‘blaming’ the economy presents a misleading, even false argument. Yes, we are reaching full employment, people are out there working. But, they are not choosing to work in nursing homes. The reasons are very clear. As the HCFA study reportedly shows, nursing assistants often go home at night overwhelmed because they had to leave someone wet, crying, in pain, hungry or thirsty. The economy is not good for people who work in nursing homes, especially direct care workers."

Most people know that there are many joys and rewards when working with the elderly. However, whenever elders are – tragically - frail, ill, confused, depressed, angry and fraught with chronic health conditions and disabilities, this extraordinary and valuable work has its dark side, unless staffing is adequate. The nursing home environment is often stressful and emotionally draining. It is not a place where most of us would be courageous enough to work. Certainly, there are nursing homes that do provide a good work place, such as the many, many homes now adventuring into culture change with leadership from new groups such as the Pioneer Network and the Direct Care Alliance. In good, caring facilities, quality jobs result in quality care. Nevertheless, thousands of people working in the nursing home industry are misused, mistreated and betrayed - even though they perform some of the most difficult, painful, often disturbing, human services in our society.

The needs of vulnerable elders are urgent! Congress should not wait for another report before it takes action to increase staffing requirements. If reimbursement to owners is to be increased, the increase must only be given if it includes the strongest possible accountability provisions. The public must be assured that the money is spent on increased staffing and increased wages and benefits, with enough funds to expand and improve nurse aide training and improved supervision. Quality jobs result in quality care for residents.

"National Public Policy Goal: A skilled nursing facility must provide services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care..."

P.L. 100-203, Social Security Act

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To read the full HCFA report, click here!