Consistent assignment—having the same caregivers consistently caring for the same patients on at least 85 percent of their shifts—sounds like a simple enough concept.
But while it has proven to be a foundational first step in moving facilities from an institutional model of care toward a person-centered model, studies show that it is currently practiced in only about 10 percent of the nation’s nursing facilities.
Recently, a group of 254 nursing facilities completed a one-year pilot program as part of a Centers for Medicare & Medicaid Services (CMS)-funded study called “Improving Nursing Home Culture.”
Participants presented their results at an outcomes congress held in October 2005, and many identified consistent assignment as an essential element of their successful improvement in both quality of care and staff retention. The results of the CMS study confirm the findings of 11 other in-depth studies that cite evidence for consistent assignment as foundation for quality improvement.
Turnover Affects Quality
While providers, working with quality improvement organizations (QIOs) over the past three years, have made significant progress on the quality measures, it is clear that nursing facility staff turnover and high staff vacancy rates are significant barriers preventing breakthrough levels of sustained improvement.
The American Health Care Association estimates that there are more than 100,000 vacant full-time nursing positions—including registered nurses (RNs), licensed practical nurses (LPNs), and certified nurse assistants (CNAs)—and an average turnover rate of more than 70 percent in the nation’s nursing facilities. Turnover leads to staff instability and vacant shifts, which, in turn, result in rushed, depersonalized care. Providers with severe staffing issues are unable to focus on quality improvement until they can stabilize their staffing.
To address this concern, Quality Partners of Rhode Island and the Colorado Foundation for Medical Care recently concluded the aforementioned CMS-funded study to explore strategies for improving the nursing facility culture.
Nursing facilities worked with their local QIOs in an effort to shift from institutionally driven care to more person-directed care and found that they needed to establish consistent assignments to structurally hard-wire the relationships needed for caregivers to know patients’ individual needs.
A Holistic Approach
Consistent assignment, also known as primary or permanent assignment, means that RNs, LPNs, and CNAs are given the opportunity to get to know their patients intimately.
The more prevalent approach to scheduling is to assign caregivers on a rotating basis, so they move from one group of patients to the next after a certain period of time, usually weekly, monthly, or quarterly. Experts estimate that 90 percent of nursing facilities have policies that require staff to rotate their assignments.
The pilot demonstrated that the one key to transformational improvement in patient care and quality of life involves a holistic approach to quality improvement that embraces the quality of work life of nursing facility staff with a commitment to individualized care. This holistic approach focuses on key areas that impact organizations and individuals, including the nature of the environment, care practices, work practices, leadership, family and community, and government.
A key tenet of quality improvement says that “every system is perfectly designed to achieve the results it gets.” In order to have different outcomes, it is necessary to examine the root causes of current outcomes and examine the systems that produced them.
It turns out that low staff morale and high rates of turnover are often directly related to the longstanding practice of rotating staff assignments. In long term care, the work has inherent meaning for people attracted to caring for others. Yet management systems such as rotating assignment can interfere with, rather than support, the caring connection with patients that often draws individuals to caregiving work in the first place.
According to research published by the late Susan Eaton, in “What a Difference Management Makes,” retention is all about relationships, and relationships are at the heart of a good working environment. This includes relationships with co-workers; across departments; with supervisors; with the organization; and, most importantly, in the case of long term care, with patients and their families.
The National Citizens Coalition for Nursing Home Reform has confirmed that patients and their families value the quality of the relationships they have with the frontline caregivers more highly than the quality of the medical care and the quality of the food. People choose to work in long term care, and stay in the field, because they care about their work, the people they care for, and the people they work with. They want to make a difference in people’s lives.
Time and again, studies show that leaders who implement systems that foster and support these caring relationships have an easier time retaining staff. With consistent assignment, it has been found that staff not only develop closer relationships with patients for whom they are caring, but with co-workers as well. Conversely, the system of rotating staff assignment continually severs relationships and inhibits caregivers’ ability to recognize patient declines and consistently address care needs.
What The Literature Shows
There are many reasons that long term care managers believe rotating staff assignment is effective. Some of the most common reasons center on issues such as fairness, preventing staff burnout, and the need for all staff to be somewhat familiar with the needs of all patients.
In other facilities, managers discourage strong relationships between staff and patients to shield staff members from experiencing grief when patients die. Finally, some are opposed to consistent assignment because they do not want individual staff members to be unfairly “stuck” with “hard-to-care-for” patients.
However, these reasons for rotating assignments are not supported by research. In fact, rotating assignments actually exacerbate low staff morale, leading to staff burnout, call-outs, quitting, and overall instability. A thorough review of the literature found 11 research articles that support the practice of consistent assignment over rotating assignment, including:
- Barbara Bowers, in “Turnover Reinterpreted: CNAs Talk About Why They Leave,” found that rotating staff made CNAs feel less valued for their skill, experience, and knowledge of the patients. “CNAs defined good caregiving as based on the establishment and maintenance of good relationships with residents,” Bowers wrote. “CNAs felt any disruption to these relationships was detrimental to the quality of the care provided and the quality of residents’ lives.”
- Suzanne Campbell, in “Primary Nursing: It works in Long Term Care,” evaluated the effectiveness of primary nursing, another term for consistent assignment, and found that for patients:
- One year after implementation of primary nursing there was a 75 percent reduction in the incidence of decubitus ulcers.
- After implementation of primary nursing, rates of patient discharge to a lower level of care increased by 11 percent, while in-patient death rates decreased by 18 percent.
- Two years after institution of a primary nursing system there was a 36 percent increase in the number of ambulatory patients.
- Campbell also recorded the effects on nursing staff and found that:
- One year after implementation of primary nursing, the turnover rate was reduced by 29 percent.
- One year after implementation, nurses reported feeling more accountable by 26 percent, more able to make and implement nursing decisions by 40 percent, and more able to plan and implement nursing care by 22 percent.
When switching from rotating assignment to consistent assignment, managers should expect some concern from staff, who have generally been told in the past that the rotating staff model is best. Managers should inform staff that based on a number of studies there is new information and that the facility must make changes to reflect this new knowledge and implement better practices. Addressing staff concerns will be the key to success in making the transition.
Following is a process that managers can follow when initiating the transition to consistent assignment:
- Call separate meetings on each nursing unit with all of the CNAs from the day shift and with all of the CNAs from the night shift.
- Begin the meetings by explaining that nursing facilities that have switched to consistent assignment have improved quality of care and life of the patients and the quality of work life for the staff.
- Place each patient’s name from the unit on a post-it note and place all of the post-it notes on the wall.
- Ask the group of CNAs to rank each of the patients by their “degree of challenge,” with No.1 being relatively easy to care for and No. 5 being very difficult (time-consuming and emotionally draining, for example). Let the CNAs agree on a number for each patient and write that number on the patient’s post-it note.
- Allow the CNAs to select their own assignments. Assignments are considered fair when each CNA in the group has amassed the same degree-of-challenge total. For example, one No. 4 patient is equal to two No. 2 patients. Therefore, the CNAs may not end up with the same number of patients to care for. Relationships with patients are important and also should be part of the decision-making process. The sequence of rooms is less important. However, proximity of the residents is important.
- Continue meeting every three months, or more frequently depending on the facility, to reexamine the assignments in order to ensure staff feel that they are fair and relationships with the patients are going well.
For additional material on consistent assignment, see the change idea sheet on consistent assignment at www.riqualitypartners.org/nursing_homes/wfr_train_3.php .
David Farrell, MSW, and Marguerite McLaughlin, MA, are project managers and Ann Gray is an intern with Quality Partners of Rhode Island, Providence, R.I. Barbara Frank, MPA, and Cathie Brady, MA, are consultants with B&F Consulting, Warren, R.I.
This article was published in the June 2006 issue of Provider.
Tags: consistent assignment, culture change, caregiving