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 Top 10 Myths Of Nursing Home Management: The Nursing Department

Maximizing skilled nursing talent in the most effective ways will result in a better distribution of staff time and better outcomes for residents.

 

Myth No. 1. Being licensed as a registered nurse (RN) or licensed practical nurse/licensed vocational nurse (LPN/LVN) means that the nurse has management skills.

Historically, most LPN/LVN programs have focused on providing students with basic knowledge of nursing, including vital sign assessment, medication administration, and wound care technique.

Although these graduates often work in charge nurse positions, they likely have not been exposed to management or leadership strategies. Even bachelors-prepared RNs may not have received any specialized coursework in management.

Administrators need to recognize that nursing education focuses on the clinical aspects of care and that supplemental courses, in-services, or support will likely be required to help transition nurses into management positions. The LPN/LVN charge nurse may require formal guidance in understanding the role of supervisor—techniques to motivate staff, coaching skills, and methods for teaching certified nurse assistants (CNAs).

Myth No. 2. The best director of nursing (DON) candidate is one who has held the position at several facilities and is willing to bring his or her staff along.

Nursing staff with a proven history within a nursing home may be more ideal candidates for the DON position than someone who has a history of working at multiple buildings. The seasoned DON may have extensive experience; however, a pattern of moving from one facility to another may prove problematic, particularly if the person has limited longevity at these facilities.

Beware of the DON candidate who is willing to bring staff along, thus leaving the former building devoid of sufficient nursing personnel. It also may adversely affect a facility’s current core of nurses, who may feel alienated from the new DON who brings a team of known performers, pitting established employees against the new group. Most importantly, consider what may happen when the DON decides to leave and take those staff members to the new facility.

A better choice may be to promote a nurse with clinical and administrative skills who can be given a mentor to help the transition. Always identify nurses with the potential to move up the ladder, while planning for the education and support they will need in order to be successful.

Myth No. 3. Medication administration can be completed within the two-hour window.

Observe staff during a med pass at 8:00 a.m. Does the med pass continue to 11:00 o’clock? Does it seem that one medication administration flows to the next without a break? Do nurses seem unable to perform other tasks such as assessments, resident teaching, staff supervision, and care planning because they are continually administering medications?

Consider having the pharmacy consultant observe an entire medication administration to determine if there are efficiencies that can be built into the system. Can some of the morning medications be moved to the afternoon or evening? Perhaps the number of medications can be separated by having one portion of the unit’s residents receiving pills at 8:00 a.m. and one portion at 9:00 a.m. This would provide a three-hour window in which the morning medication pass can be completed.

Myth No. 4. Nurses inherently understand how to perform the Braden Scale for the assessment of pressure ulcer risk.

Don’t assume that any nurse inherently understands how to complete a Braden Scale, as the questions may not be as intuitive as they look.

For example, the domain “sensory perception,” the ability to respond meaningfully to pressure, may be affected by diminished cognition from dementia, narcotic use commonly found in hospice residents, or people affected by strokes who cannot feel or respond to pressure on their sacrum or heels.

It may be difficult for nursing staff to determine if a resident has adequate nutrition upon admission if the resident’s weight history is unknown or if their nutrition laboratory values (albumin, prealbumin) were not sent from the hospital.

Asking a resident if clothing fits more loosely may be a better indicator of weight loss than
asking the resident about his or her weight history.

Specialized in-service education addressing the six domains of the Braden Scale may be a valuable tool in accurately identifying risk, as well as implementing appropriate interventions at the time of admission.

Myth No. 5. The DON is the best person in the nursing department to develop the staffing schedule.

Although sufficient numbers of appropriately trained staff is one of the most important factors in the provision of clinical care, the DON needs to delegate this responsibility. The most clinically relevant person in the building should not be devoting time to completing the schedule, but should have oversight in its completion and implementation.

Myth No. 6. CNAs should continue to perform nonclinical duties.

CNAs have traditionally performed activities that could be performed as efficiently by the staff of other departments, providing greater opportunity for them to engage with residents, to understand the individual resident preferences, and to perform restorative nursing activities such as ambulating residents from the entrance of the dining room to the table so they may sit in dining room chairs rather than wheelchairs.

Since salivation is the first stage of digestion, discussing what is on the menu for the upcoming meal and asking residents about how they prepared certain dishes may stimulate their ability to eat.

So instead of having CNAs pass fresh water or fill ice pitchers, let this task be done by the dietary department. Instead of bed making, assign it to housekeeping. Instead of CNAs attending to residents for outside appointments, therapeutic recreation staff could do it. It is likely that dietary, housekeeping, and therapeutic aides’ pay rates are less than that of CNAs and are easier to hire.

Myth No. 7. Staff enjoy and derive benefit from attending the same in-services given by the same staff in the same format.

Staff who have been loyal employees for years are punished for their loyalty when the same educational programs are provided year after year. Instead, consider identifying CNAs that excel in certain areas and have them perform the in-services, such as body mechanics. CNAs may value the in-services demonstrated by their peers, as well as appreciate the opportunity to be recognized by the facility for their skills.

In-service programs that engage staff by having games, quizzes, or other forms of interaction may provide better outcomes. Avoid posting in-service programs using the word “mandatory.” Instead, offering food may increase the likelihood of attendance, participation, and carryover to clinical care.

Asking staff for educational topics, having the medical director and consultants provide programs, and using YouTube videos may enhance the experience and translate to improved resident outcomes.

Myth No. 8. CNAs should obtain vital signs and report significant changes to the licensed nurse.

Although many CNAs are competent in obtaining temperature, pulse, respirations, blood pressure, and pulse oximetry readings, the interpretation of vital signs is an important skilled nursing intervention than cannot be delegated.

While it is important that CNAs (and other staff) be encouraged to stay alert to and report any changes they note in a resident’s condition, finding mechanisms to ensure that CNAs are providing the licensed nurses with timely vital sign readings may prove difficult. Instead, it may be more efficient to have licensed nurses take the vital signs, particularly for targeted residents, so that abnormalities can be appropriately identified and acted upon.

Myth No. 9. Abuse education programs should focus primarily on the nursing staff.

An abuse prevention program, focusing on the definitions and examples of abuse, neglect, financial exploitation, and passive and active neglect, will be more effective if all staff of all departments participate in the program. Although nursing staff have the most intimate interactions with residents, all departments have the ability to see abuse and intervene.

When reporting new, unexplained bruises, nursing staff must include the color, shape, and location of the bruise in order to know which staff to interview during an investigation. In most cases, fresh bruises are red, blue, or purple, and when they age, they become brown, green, and yellow. A resident with bruises of multiple colors has likely been injured over a period of time, not just one incident. A resident with finger-like bruises on the upper arms may have been roughly handled. All incident reports should contain information about these characteristics.

Myth No. 10. Nurses are proficient in documentation, and their notes fully reflect their assessments, interventions, and clinical decision-making skills.

The ability to capture appropriate information in clinical records remains elusive to many providers in all health care settings. Practitioners should keep in mind that while notes are intended to communicate care needs within and between disciplines, notes should also describe what special services the facility provided that justify the cost of resident care.

Rather than documenting that wound care was provided, the narrative note should identify if the wound is improving or deteriorating, since the treatment administration record is the source of documentation that wound care was provided.

Instead of writing that all due medications were administered, the nursing staff should comment on the resident’s response to one or more drugs that were given.

Instead of simply recording vital signs in the narrative notes, the skilled nurse should interpret these findings in relationship to the resident’s baseline vital signs.
Nursing staff who include the statement “will monitor” in a narrative note should instead specify what should be monitored so that subsequent staff can monitor those factors as well.

Administrative staff should take the opportunity to review a number of clinical records throughout the course of the week and identify areas in which the professional staff could improve their note-writing skills.
Addressing these 10 nursing department myths should enhance the administrator’s ability to improve the function and oversight of this critical clinical entity. 
 
Ilene Warner-Maron, RN, PhD, is assistant professor, health services director, Interdisciplinary Health Services, at Saint Joseph’s University in Philadelphia. She can be reached at (610) 660-1586 or iwarnerm@sju.edu.
 
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