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 Consistent Assignment Creates Familial Bonds

Residents feel sense of security when they can rely on someone.

 Contributing Editor

Imagine this happening: A certified nurse assistant (CNA) accidentally drops a resident during a transfer. The frail, elderly individual is bruised, sore, and has a skin tear. When an investigation is conducted, the resident defends the CNA and refuses to blame her for the accident. She says that the caregiver always is conscientious and responsible and treats her with genuine care and concern. She states emphatically, “I will not help you fire her.”
 
Or consider this story: A very elderly—over age 100—resident passes away. She has no family. She leaves behind a box of belongings, including photos and other personal items. Instead of discarding them and forgetting about a life and what it meant, the resident’s assistant asks to keep the items. She says that she wants to keep the woman’s memory alive. She says, “We are her family now.”
 
​Click HERE to see what nursing staff have to say about consistent assignment.

A Family Affair

These are true stories that epitomize the value of consistent assignment. A growing number of long term care facilities have embraced this concept and implemented it with great success, and the investment is reaping tremendous dividends—happier residents and families, fewer behavioral problems, greater staff stability and lower turnover, and more referrals. Staff, residents, and family members alike are so enthusiastic about consistent assignment that facility leaders are wondering, “Why didn’t we do this sooner?”
 
While establishing and maintaining consistent assignment requires some work, many say it’s as easy as teamwork, flexibility, and trust. These elements not only help facilities move foreward with consistent assignment, they flourish as care becomes a family affair with everyone working together to create caring, safe, and homelike environment.
 

"The CNA gets to know the resident very well and is familiar with the person’s habits, routines, and behavior. If the resident’s behavior changes—however subtly—the CNA is the first one to notice," says Sister Pauline, administrator, Teresian House Center for the Elderly, a church-affiliated long term care facility in Albany, N.Y.

The CNA’s familiarity with the resident also can prevent behavioral changes caused simply because an assistant doesn’t know about a resident’s routine, pet peeves, or preferences. Sister Pauline gives an example from her own family. “My mother [who is a resident at Sister Pauline’s facility] always wore a scarf, and her CNAs know this, so they make sure she always has a scarf.”
 

Residents, Families, Staff Like It

According to Barbara Baylis, RN, MSN, senior vice president of clinical and residential services for Kindred Healthcare in Louisville, Ky., “The residents and families like having someone they can depend on every day. And they don’t have to tell their story over and over again.” As a result of consistent assignment, she says, facilities can expect to see a decrease in resident and family complaints and concerns.
 
The residents and families aren’t the only ones who benefit. “Consistent assignment makes it much easier and more pleasant to come to work,” Sister Pauline says. “They can plan their schedules according to their residents. They know who gets up early, stays up late, and so on. They know how their residents like their rooms and what they want on their beds. It makes for real harmony among everyone involved.”
 
Consistent assignment also enables staff to detect problems earlier and devise individualized solutions to challenging situations. For example, Barbara Frank, MPA, co-founder of B&F Consulting, a Warren, R.I.-based company that works with nursing facilities and other organizations on staffing, culture change, and quality improvement, says, “I hear all the time from CNAs that they can anticipate residents’ needs all through the day and respond to them promptly and proactively.”
 
She cites a story from long term care physician Al Power, MD, who was trying to prevent pressure ulcer development in a high-risk resident. The nursing facility team kept attempting to turn the woman on her side facing the window, and she kept turning back on her other side toward the door. Her CNA observed that the resident was a bird lover and suggested hanging a bird feeder outside the window. The team did as she suggested, and it worked.
 
“Consistent assignment lets you intervene in a way that is likely to produce positive outcomes. And staff have a real sense of personal accountability when they work this closely with their residents,” Frank says.
 
Starting on the road to consistent assignment is easier for most facilities than they realize. As Sister Pauline notes, “Many facilities have been doing it for awhile, but they didn’t have a name for it.” Baylis says, “We initiated this over three years ago when it became an Advancing Excellence Campaign goal. It is rooted in primary nursing and based on a staffing model that has been around for about 30 years.” Currently, about 99 percent of Kindred facilities have consistent assignment.
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Assess, Stabilize, Start

A first step to establishing consistent assignment, says Dwight Tew, vice president, talent solutions, for Brookdale Senior Living in Brentwood, Tenn., is determining what staffing additions or changes are needed. Then it is essential to make sure that “you find the right people for each team and provide them with ongoing education.”
 
Robin Arnicar, RN, CDONA/LTC, director of nursing at the Renaissance Gardens, Silver Spring, Md., adds, “You have to conduct an honest evaluation of your staffing numbers. If you don’t have enough staff, you need to do a root cause analysis of why.” Then, she says, the facility needs to start recruiting and hiring needed staffers.
 
Establishing staff stability is key, agrees Frank, to improved performance. “It’s hard to maintain consistent assignment if you have to shift people around because you don’t have reliability. In addition, you need cohesive teams on each shift,” she says. “You have to establish effective ways for teams to resolve issues as they arise,” Frank continues, “otherwise, CNAs can feel stuck and alone in a challenging situation, and that is the kiss of death.”
 

Barriers May Crop Up

While consistent staffing requires leadership support and staff buy-in, the concept needs little selling. Most leaders and staff inherently understand the benefits. However, this doesn’t mean that there aren’t barriers to implementation. For example, says Frank, “CNAs may worry about being stuck with someone who is hard to care for. However, if you support CNAs, it alleviates people’s fears that they will be left alone to deal with a difficult situation.”
 
Knowing that they have support can help give CNAs the patience and time to bond with and understand residents who—at first—may seem difficult. For example, Frank says, “There was a post-stroke resident in one facility whose stroke made it so she could only say ‘no’ to everyone about everything. When the organization established consistent assignment, the woman’s CNA got to know her and could tell from her eyes or other nonverbal cues when she actually meant ‘yes.’”
 
Frank stresses, “It’s critical to maintain consistent assignments that staff perceive as fair. Staff have to trust the fairness of the process. You need to constantly trouble-shoot and make sure people get help when they need it.”
 
Another barrier that needs to be overcome up front is the myth that it is better for staff to know all assignments so that they can work anywhere. “This concept seems so anti-relationship,” says Frank. She adds that most staff like knowing what to expect when they come to work every day.
 
Baylis agrees. “CNAs don’t want to relearn everything all the time. They want to go to work and get started right away,” she says. “They like being efficient and feeling confident about their work.”
 

Setting Up For Success

Of course, preparation requires the resident’s involvement. As Sister Pauline says, “Before the resident is admitted, we do a pre-admission assessment in which we ask many questions such as what time they get up, what side of the bed they get up on, and what they like to eat for breakfast. We try to mimic their regular schedule so that their admission is seamless.”
 
Later, the CNA and the resident make a care plan just between the two of them that is posted in the bathroom. The nighttime assistant does the same. “On the first evening, the CNA calls the family and tells them how the resident is doing. Then the daytime aide calls in the morning to tell them how their loved one spent the first night. Immediately, they learn about this relationship with the caregiver; and it puts their minds at ease,” Sister Pauline says.
 
Arnicar suggests seeking out informal facility leaders—people who are influential in their units—and using them to establish a peer team. “These people can move a new program forward or be its demise. You need to recognize that they are influential and ask for their help in explaining the benefits of consistent assignment,” she says.
 
Whatever plans a facility makes to implement consistent assignment, Arnicar suggests starting small and slow. “Don’t do the whole building in one day. Start with one unit or neighborhood, make it work there, and then move on to the next neighborhood,” she says, adding, “Empower staff to come up with and share ideas along the way.” But don’t forget to set rules and structure, she cautions.
 
“I went to one building, and they had given staffing over to the staff but never gave them rules. They ended up with 55 different schedules, scheduling gaps, and tons of staff burnout and resident complaints.” Finally, as the facility implements consistent assignment, it must plan a way to measure results. Arnicar suggests tracking outcomes such as staff, resident, and family satisfaction; number of complaints; number of staff call outs; turnover; and clinical issues such as weight loss, falls, and use of antipsychotics.
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Plugging Into Smooth Scheduling

Solid organization and strong processes will enable the consistent assignment program to move forward more smoothly. One option to manage staffing is the use of scheduling software, such as a program that enables users to create an active schedule. It enables facilities to track staffing and account for vacations and call outs.
 
These systems can be as simple or sophisticated as necessary. For example, they can be designed to send an automatic message to only specific individuals requesting coverage for a call out and enable a sudden absence to be filled by an appropriate substitute in 10 to 15 minutes.
 
Mark Woodka, chief executive officer of OnShift Software, a Cleveland, Ohio-based scheduling software producer, says, “A facility can’t commit to consistent assignment and then implement the program in a disorganized way. People need to know the processes and trust that they will work. Otherwise, you will scramble when you run into conflict.” He notes that his company maintains a template of the master schedule for clients and helps keep it consistent month in and month out.
 
Scheduling programs can help streamline scheduling and help facilities track staffing over time. They can contribute to cutting down on the use of agency CNAs or nurses, and they can take the burden off of busy managers. However, facilities should consider the costs of these systems and weigh the expenses with their specific needs.
 
For example, facilities can purchase the license to use scheduling software for a few hundred dollars plus a subscription fee for regular updates. Or they can get the software subscription with a fully hosted service that includes customization, service, and support. Depending on the organization’s size, this could cost several hundred dollars annually or more.
 
Whether or not a facility chooses to use specialized software or outside companies to manage scheduling, managers involved in setting and maintaining schedules need to be involved from the start. “The people are crucial, and you really need their buy-in. You need to help them understand that consistent assignment ultimately will make their job easier,” says Arnicar. She suggests having this person talk to a scheduler at another facility that has implemented consistent assignment successfully.
 

Maintaining The Momentum

Teamwork among the CNAs is essential for consistent assignment. However, it doesn’t always happen quickly and easily, especially when people come from different backgrounds and experiences. Sister Pauline says at her facility, CNAs “meet weekly and do huddles as a shift. As a result, they work together and support each other.”
 
They also make sure that new hires know what to expect and what is expected of them. She says, “When an employee comes in looking for a position, we first have them watch a video about working here.”
 
Hiring the right people in the first place is essential to maintaining consistent assignment. As Tew says, “We stress to interviewees that we focus on health and wellness and making residents as functional as possible for as long as possible.” He says that they listen for personal stories or other indications that prospective employees “have a desire to work for the greater good and serve the elderly.”
 
Tew talked to employees at one facility who stressed that they liked theri jobs because of the residents, the teamwork, and the leadership. They enjoyed an atmosphere where they’re caring for residents and having fun doing it. They look at it as something they want to do versus just a job they do for a paycheck," he says.
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Managers Must Take The Lead

Tew says supervisors and team leaders have a strong role to play in ensuring the success of consistent assignment.
 
“They need to create an environment where associates feel rewarded, encouraged, and understand their jobs and what is expected of them,” he says, adding, “Managers need to be able to motivate staff and make them feel that they are part of the organization. They need to create a safe environment where staff can suggest improvements and changes and where they share the same level of commitment as managers.”
Not only do team members need to feel that they can express opinions and share observations, they also need to know that management will act on them.
 
“If you ask for CNAs’ input, you have to take it seriously and respond to it,” says Frank.
 

Busting Burnout

Even when facilities hire and keep great people, they need to protect them from burnout. There are many ways to accomplish this. For example, staff can volunteer to care for residents with whom they have established good relationships.
 
Elsewhere, full-time relief workers might work strictly for two people—for example, the person consistently handles Mary’s three days off and Bob’s two.
 
Facilities also should consider the demands of each resident in making assignments, Baylis says. “I may have nine residents, while you only have six because yours require more care and assistance. Assignments have to be equal not in number but in amount and level of care required. There needs to be equality and teamwork,” she says.
 
Another way to maintain staff satisfaction with consistent assignment is not to force caregivers to work with particular residents. As Baylis says, “Very rarely, we have situations where the caregiver and the resident don’t click, and when that happens, we switch them out and someone else cares for the resident. We always try to make accommodations.” However, she notes, “team members usually develop strong bonds with the residents and families, and none of them want to change.”
 

Crowing About Accomplishments

Facilities that have established consistent assignment successfully are wise to promote them as part of their culture. “It’s a core business strategy for us,” says Tew. “It’s a consistent message being delivered from the top down.”
 
He says that his company uses “a lot of people pictures” in recruiting and marketing materials. “It may seem corny,” he admits, but he notes that it reinforces the person-centered approach to care emulated by consistent staffing.
 
Tew also says that staff themselves are the best advertisement. “When you see that people are smiling, friendly, and happy as you walk through the facility, that says a great deal.”
 
Maintaining and promoting the individualized approach to care is key to successful consistent assignment.
“If one resident leaves and that person showered in the morning, you don’t just put a new resident in the same routine just because it’s convenient. If you do, it can set you up for problems,” says Sister Pauline. “You need to involve the social worker and find the best place, the best routine for each resident.”
 
The facility also needs to prepare residents for staff vacations and absences. As Sister Pauline says, “The resident’s personality can change on a day the aide isn’t there.” She suggests having CNAs tell residents when they’re leaving for the day and remind them when they will be out the next day. The relationships with the resident are so strong that even the family misses the caregiver when he or she is out. “Families will get upset if something happens and their family member has someone different caring for him or her. Often, they will visit more often and stay longer when the regular caregiver is out,” she says.
 
The sense of family that comes from consistent assignment is very real. As Karyn Leible, RN, MD, CMD, chief clinical officer, Pinon Management in Colorado, and president of AMDA—Dedicated to Long Term Care Medicine, says, “Residents love it when staff bring in their kids or grandkids. It becomes an extended nuclear family.” Leible, who first practiced consistent assignment as a nurse many years ago, adds, “My son used to round with me when he was two. When I was listening to a resident’s heart with the stethoscope, he’d be sitting on the person’s lap with a toy stethoscope.”
 
Another time, Leible brought her son into her facility on Christmas Eve. While she worked, he sang carols and baked cookies with the residents. “Many of these people don’t have anyone else. They like having someone special to care for them,” she says. “Connecting to others is a human need. These relationships are key, and consistent assignment builds powerful, caring, and important connections that have a real impact on everyone involved.”
 
 

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