Nursing Staff and Quality of Care in Nursing Homes

Meridean Maas, Ph.D., R.N., F.A.A.N., Kathleen Buckwalter, Ph.D., F.A.A.N., and Janet Specht, M.A., R.N.

This paper focuses on a review of literature and research regarding nurse staffing and quality of care in nursing homes. Background information for this review was obtained through computerized literature searches, through solicited contributions and personal communications from nurse researchers and long-term-care scholars, and from presentations at a special panel session convened at the Gerontological Society of America meeting in Atlanta, Georgia, in November of 1994. The first section of the paper reviews the background and historical development of nursing homes in the United States, while the second section describes the current status of institutional long-term care. The next two sections discuss the future demand for nursing home care and some selected issues in long-term care. The fifth section presents a detailed review of research relevant to the linkage of staffing and quality of care. The final three sections outline research questions and areas that need to be studied, present a case study of staffing and quality in an exemplary nursing home, and set forth recommendations for policy initiatives.

Dr. Maas is professor, Dr. Buckwalter is distinguished professor, and Ms. Specht is research program assistant and doctoral candidate at the University of Iowa College of Nursing.



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--> Nursing Staff and Quality of Care in Nursing Homes Meridean Maas, Ph.D., R.N., F.A.A.N., Kathleen Buckwalter, Ph.D., F.A.A.N., and Janet Specht, M.A., R.N. This paper focuses on a review of literature and research regarding nurse staffing and quality of care in nursing homes. Background information for this review was obtained through computerized literature searches, through solicited contributions and personal communications from nurse researchers and long-term-care scholars, and from presentations at a special panel session convened at the Gerontological Society of America meeting in Atlanta, Georgia, in November of 1994. The first section of the paper reviews the background and historical development of nursing homes in the United States, while the second section describes the current status of institutional long-term care. The next two sections discuss the future demand for nursing home care and some selected issues in long-term care. The fifth section presents a detailed review of research relevant to the linkage of staffing and quality of care. The final three sections outline research questions and areas that need to be studied, present a case study of staffing and quality in an exemplary nursing home, and set forth recommendations for policy initiatives. Dr. Maas is professor, Dr. Buckwalter is distinguished professor, and Ms. Specht is research program assistant and doctoral candidate at the University of Iowa College of Nursing.

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--> Background And Historical Development Of Nursing Homes In The United States From Almshouses to Nursing Homes Nursing home policy was developed from social welfare issues regarding care of the poor. A strategy known as ''indoor relief" was developed in Elizabethan England when social planners used almshouses to care for the poor, who were divided into the "deserving poor" (those who were unable to work) and the "undeserving poor" (those who were perceived as morally corrupt because they were able to work). The poor elderly were housed in almshouses and exempt from moral judgments because of their age and inability to work (Hall and Buckwalter, 1990). In the United States in the 1920s, almshouses were funded by the states and were used to continue the policy of providing indoor relief for the deserving poor who were unable to be employed in the factories, as well as providing care for the blind, chronically ill, mentally ill, and frail and old individuals. In 1923, about half of the 78,000 residents of almshouses were elderly and infirm. Society began to protest the housing of the infirm elderly with the poor and insane and Congress, because of this public pressure, stipulated that persons in public institutions should not receive old age funds; people in boarding houses, however, were eligible. Not surprisingly, this legislation prompted a sharp increase in the number of boarding homes in which nurses were hired to care for the frail and chronically ill. Thus, many boarding homes became known as nursing homes (Kalisch and Kalisch, 1978; Vladeck, 1984). Also in the early 20th century, private care homes emerged for elderly widows of various ethnic or religious groups (e.g., Lutheran homes, Jewish homes), which served as the precursors for today's charitable and nonprofit nursing homes (Vladeck, 1984). Nursing homes really began to develop following passage of the Social Security Act of 1935, which provided payment to individual beneficiaries and thus turned indoor relief into "outdoor relief." That is, community-based services began to emerge that prevented the need for almshouse placement (Kalisch and Kalisch, 1978; Vladeck, 1984). With passage of the Kerr-Mills Medical Assistance to the Aged Act in 1950, which allowed for direct payment to care providers, and with increases in the number of older adults in the population, the nursing home industry boomed. In 1954, the American Nursing Home Association lobbied for and won the right for nonprofit nursing homes to be built in conjunction with hospitals using Hill-Burton funds. Thus, nonproprietary homes were moved into the medical-surgical domain where, after passage of the Medicaid and Medicare Acts in 1965, they were required to meet strict federal nursing standards, creating the skilled-level facilities of today. Standards of care relaxed somewhat during the Nixon administration, and proprietary homes could apply for small business develop-

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--> ment loans, which excluded them from the strict federal nursing criteria and led to the creation of intermediate-level care facilities with criteria developed by individual states for reimbursement under Medicaid (Vladeck, 1984). Altogether, between 1980 and 1990, there was a 24 percent increase in nursing home occupancy rates (McKnight's Long-term Care News, 1993). The percentage of residents requiring more hours of care, more services on a daily basis, and having higher acuity levels has also risen over the past few years. Indeed, 43 percent of all Americans who passed their 65th birthday in 1990 are expected to use a nursing home at least once in their lives (Murtaugh et al., 1990). Development of Long-Term Care for the Mentally Ill Elderly For the first half of the 20th century, the mentally ill elderly were systematically admitted to state hospitals, which provided them with custodial care (Kermis, 1987). By the late 1950s and early 1960s, however, the indoor relief policy regarding care of the mentally ill began to change as mental health programming was reoriented to a system of outpatient psychiatric treatment, rehabilitation, and prevention. Both the Kennedy and Johnson administrations supported deinstitutionalization of mental patients in the large state hospitals and the creation of community mental health centers to provide outpatient treatment. Thus, the population of the state mental hospitals, which included many elderly, decreased by as much as 66 percent (Kane, 1984), and those elderly who continued to require institutionalization were most often placed in nursing homes to receive care (Mechanic, 1980). Unfortunately, the medical focus of most nursing home administrators and personnel left them unprepared to care for those elders with cognitive, behavioral and affective disorders, and nursing homes were faced with large numbers of residents who failed to respond to programming in a conventional manner, did not sleep at night, and became violent when confronted with other residents (Hall and Buckwalter, 1990). Research by Zimmer and colleagues (1984) found that 64 percent of elderly residents of skilled nursing homes had significant behavioral problems, of which nearly 23 percent were classified as "severe." Despite the fact that 58 percent of these patients were receiving psychoactive drugs, both psychiatric diagnoses and consultations were absent. Similarly high rates of mental illness and cognitive disorder (70 to 80 percent) in the absence of active treatment were reported by Roybal (1984) and Rovner and Rabins (1985). By and large, health planners and economists failed to recognize the additional staffing and financial burdens these mentally ill and cognitively impaired residents placed on the nursing home system (Vladick and Alfano, 1987). The current trend, however, is for integrated interdisciplinary treatment teams to provide psychiatric care in nursing homes, an approach that allows for the use of psychopharmacologic, psychoeducational, behavioral, and family or social interventions. Preliminary outcome data suggest, moreover, that this more comprehen-

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--> sive approach results in the use of fewer psychotropic medications, more effective resolution of behavioral problems, and decreased costs related to the need for hospitalization (Dey, 1994). Current Status Of Institutional Long-Term Care Institutional long-term care can be viewed from several vantage points. This section presents data on the number and types of facilities and on the mix of residents cared for in those facilities. Federal and state regulations affecting long-term care and how those regulations affect reimbursement for care are discussed. Finally, staffing issues, including staffing requirements, staff mix and qualifications, the nature of nursing home work, and staff salaries, are described. Numbers and Types of Homes Long-term institutional care of elderly residents falls into two major categories: (1) traditional nursing homes, which primarily are facilities that provide either intermediate-level nursing care or skilled nursing care, but might also include "board-and-care" residential homes, and (2) recent alternatives to the traditional nursing homes, such as foster care homes, family homes, or assisted-living homes. Numbers of homes are presented to illustrate trends in the availability of institutional long-term-care options. Traditional Nursing Homes Today, the primary providers of institution-based care for dependent elders are the more than 20,000 intermediate and skilled nursing homes. Although the Omnibus Budget Reconciliation Act of 1987 (OBRA 87) eliminated the distinction between skilled and intermediate nursing homes, Title XIX continues to distinguish the two types for reimbursement. According to the 1985 National Nursing Home Survey (NCHS, 1987), 75 percent of nursing homes were proprietary, 20 percent voluntary nonprofit, and 5 percent government operated. Forty-one percent were operated by nursing home chains and about 50 percent were independently operated. Proprietary homes provided 69 percent of the nursing home beds, voluntary nonprofit homes provided 23 percent of the beds, and public homes 8 percent. Eighteen percent of the available beds were skilled nursing, 30 percent were skilled nursing and intermediate level, 28 percent were intermediate level only, and 25 percent were not certified. One-third of the nursing homes had fewer than 50 beds, about another third had between 50 and 99 beds, 28 percent had 100 to 199 beds, and only slightly more than 6 percent had 200 or more beds. Another type of traditional nursing home is the board and care home. A board and care home differs from intermediate- or skilled-level nursing homes in

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--> that continuous care provided by licensed nurses is not required. Board and care homes outnumber skilled and intermediate nursing homes by more than 2 to 1 in the United States and have an average size of 15 beds (Brown University Long-Term Care Quality Letter, 1994). Both nursing homes and board and care homes have high occupancy rates, 91.5 percent and 85.6 percent respectively. However, the 1991 National Health Provider Inventory, mailed to providers and analyzed by the National Center for Health Statistics (NCHS), found wide geographic variations in the prevalence of nursing homes versus board and care homes or home care (Brown University Long-Term Care Quality Letter , 1994). The Midwest relied heavily on regular nursing homes, little on board and care, and moderately on home care. The Northeast relied heavily on all three, with much more home health care use than in the other regions. The South showed moderate usage of all three types of care, and the West relied on board and care more than any other region. Nationwide, the study counted 15,511 nursing homes, with 1.6 million beds and 1.5 million residents. While the number of free-standing nursing homes has dropped by 1,644 since 1986, the number of nursing home beds has increased by 60,000—meaning that existing nursing homes are becoming larger. Recent Alternative Long-Term-Care Models A number of residential care models have recently arisen in response to the need to develop alternatives to the medical model emphasis in most traditional long-term-care facilities. These alternatives include a range of state-licensed residential living environments such as foster care, family homes, residential care facilities, and assisted-living arrangements (Wilson, 1994). These variations in facilities are possible because there are no federal guidelines standardizing long-term residential care, and state regulations vary widely regarding environmental, programming, and nursing care standards, with minimum staffing ratios ordinarily set quite low. Although residential care settings vary in size (ranging from small private homes accommodating up to 4 residents, to large congregate care facilities that may care for more than 100 residents), all offer assistance or care and share with the residents the responsibilities for activities of daily living. Ideally, the care provided is flexible, resident and family oriented, and intended to optimize individual dignity, functioning, health, and well-being. Because these alternative facilities also provide care for demented residents, the physical environment and design features of the facility should support the functioning of the impaired older adult and accommodate difficult behaviors and diminished abilities (Alzheimer's Association, 1994). Assisted living, for example, is a model of supportive housing that is growing rapidly because of consumer preferences and lower costs than those associated with traditional models of long-term care (Wilson, 1994). The state of Oregon has been a leader in developing standards of assisted-living care for the

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--> purposes of licensure and evaluating resident outcomes. Residents are entitled to a private apartment (shared only by choice) that includes a kitchen, a bath with roll-in shower, locking doors, and temperature control capability. Routine nursing services and case management for ancillary services are provided. Data show that residents in these Oregon assisted-living facilities have a remarkably high level of disability: 84 percent have some mobility impairment, 75 percent require assistance with medications, and 63 percent require assistance with bathing. Most importantly, the orientation of staff toward the residents is to empower them by sharing responsibilities, enhancing choices, and managing risks (Wilson, 1994). Because of the lack of regulations and standards, consumers need to question providers about all aspects of services, including the philosophy of care, number and type of staff, staff training, staff supervision, and costs, to determine if resident and family needs will be met. The sub-acute unit is another alternative long-term-care model. With the advent of the Medicare prospective payment system and use of diagnosis-related groups (DRG) as the basis for payment in hospitals, older adults began to be discharged "quicker and sicker" to nursing homes. In the United States, this early discharge of older adults from hospitals has led to a movement to create sub-acute care units in nursing homes, discussed more fully below in "Future Demand for Institutional Long-term Care." These units do not necessarily focus on frail older adults in the latter stages of life, but are in response to the economic changes affecting hospitals and tend to reinforce a medical model of care (Lyles, 1986; Ganroth, 1988; Swan et al., 1990). Case-Mix Data According to Fries (1994), case-mix refers to distinctions of residents related to resource use where resource use is primarily defined as a ratio of nursing time to costs. Nursing home residents are a heterogeneous mix of vulnerable adults whose ages may span more than 50 years. Residents are also getting older; those over the age of 85 years constitute about 42 percent of nursing home residents, up from 34 percent in 1980. Despite the dramatic increase in the number of nursing home residents who are age 85 or older, there are more than 181,000 (12 percent) residents under the age of 65 in nursing homes (McKnight's Long-term Care News, 1993). As noted earlier, a high percentage (around 75 percent) of persons who reside in nursing homes are reported to suffer from a chronic dementing process or some form of mental health or behavioral alteration. Most of these residents also have medical and personal care needs that require ongoing staff intervention and support. For example, about half (51 percent) of residents are incontinent of urine. Physical care issues, low staff ratios, regulatory issues, and inadequate staff preparation and training often mean that residents with behavioral impairment are still poorly understood and tolerated in the long-term-care environment (Hall, 1995).

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--> Regulations and Reimbursement Over the past few years, a paradigm shift has occurred in long-term care—from a biomedical treatment orientation and custodial care approach to a more social-behavioral model of care with a rehabilitative focus (Burgio and Scilley, 1994). However, implementation of a social-behavioral model of care has been constrained by regulations and reimbursement that are still guided by a medical model and by tensions between federal and state jurisdictions for regulating and reimbursing nursing homes. Issues of staffing and care policies in traditional long-term-care facilities are influenced by a combination of federal and state regulations. Because the federal government is the only payer for Medicare and shares the rapidly increasing payment with states for Medicaid, and because consumer concerns intensified, federal interest in regulation increased and resulted in the passage of OBRA 87. Yet state regulatory groups did not control the development of OBRA regulations and do not have the option to not implement them. The OBRA 87 regulations mandated higher standards for quality care, but federal and individual state reimbursement formulas have not necessarily changed to enable nursing homes to better meet the higher standards. Enactment of OBRA 87 resulted in regulations that required nursing homes to adopt a more active social-behavioral treatment model for residents. In contrast to an earlier emphasis on facility cleanliness and the physical plant, the new regulations are more resident focused, emphasizing systematic assessment and individual plans of care that foster the highest achievable level of resident well-being. In addition to restricting the use of antipsychotic medications for the treatment of behavioral problems, OBRA also mandated more training for each nurse's aide (a minimum of 75 hours of initial training that addresses psychosocial as well and physical health care, and 12 hours of in-service education annually), as well as assurance of skill competency (Burgio and Scilley, 1994). Thus, with OBRA 87 setting the standard for quality of care in long-term-care facilities, the nursing home industry today is among the most highly regulated businesses in America. Beset with regulations developed in response to perceived abuses and poor quality care, licensed nursing homes are charged with providing care that meets the vast needs of diverse residents, yet often they must try to meet that charge with only minimum reimbursement and inadequate staffing (Hall, 1995). Success or failure to meet the government mandates is evaluated by the facility's own quality assurance programs, as well as surveys conducted by multiple agencies, care review boards, and state ombudspersons who investigate complaints (Hall, 1995). A report by the Department of Health and Human Services Office of the Inspection General indicates that most states are doing an adequate job of carrying out their survey responsibilities as outlined under OBRA 87. However, survey staff issues, enforcement, and inspections remain problematic, and there is need for improved training of state surveyors

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--> and better communication between state and federal surveyors in terms of consistent application of guidelines for quality of care (McKnight's Long-term Care News, 1993). In addition to the surveying difficulties, the lack of attention to how reimbursement affects the ability of homes to meet quality standards is a serious concern. Nationally, there is some movement toward case-mix reimbursement for nursing home care, although most states continue currently to reimburse by capitated cost-based systems—systems that are limited by a cap regardless of the cost to provide the care. Use of this system tends to encourage nursing homes to preferentially accept private pay and minimal care persons, rather than persons whose care is reimbursed by Medicaid. The lack of federal regulation coupled with wide variation in state regulations also affects alternative forms of long-term-care facilities and the level of reimbursement available to those facilities. Currently there are few regulations for assisted-living facilities, and reimbursement under Title XIX for assisted living is limited to a few states. Public expenditures for community-based services are relatively small compared to those for nursing home care (O'Shaunessy and Price, 1987). Medicaid, which is the principal source of funding of health care services for low income persons, finances mostly nursing home care and was not designed to support a full array of social and other long-term-care community-based services. A few states provide some reimbursement, but because of a lack of Medicaid reimbursement most deny persons who cannot privately pay for this option. Some, but not all, long-term-care insurance policies cover assisted living and other arrangements alternative to nursing home care. There also is some controversy surrounding reimbursement rates for special care units, because of a lack of data to support whether or not a higher cost of care is justified on these units. Staffing, Staff-Mix, and Qualifications Over 1.5 million residents are cared for in nursing homes by 1,200,000 full-time equivalent (FTE) employees each day, of whom 700,000 FTEs provide some form of nursing or personal care. Nursing aides (designated by the acronym NAs and also referred to in this paper as nurse aides, nurse assistants, and nursing assistants) and orderlies account for over 40 percent of a home's total FTEs. Registered nurses (RNs), on the other hand, make up less than 7 percent of a nursing home's total FTEs and less than 20 percent of a facility's total nursing staff. Of the estimated 1.5 million employed RNs in the United States, fewer than 100,000 are employed in nursing homes (NCHS, 1988). And yet nothing is more important than the characteristics of the nursing staff in terms of determining the residents' quality of life. Staff interaction with residents and the nature of the relationship that develops between them is what matters most to residents, far

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--> more than the administrative philosophy or decor of the facility (Kayser-Jones, 1989). Data from the 1985 National Nursing Home Survey (NCHS, 1988) indicated that nursing homes had an average of 71.4 FTE staff per 100 beds, with an average of 5.2 RN FTEs, 7.4 LPN FTEs, and 30.8 NA FTEs per 100 beds. Proprietary homes averaged 4.3 RN FTEs per 100 beds, while voluntary nonprofit homes averaged 6.7 RN FTE per 100 beds and government-operated homes 7.4 RN FTEs per 100 beds. Regulations are such that very few nursing homes (5.6 percent) have an RN on duty 24 hours a day (Jones et al., 1987). Because available staff are distributed over a 24-hour period, for every 100 beds the average staffing is 1 RN, who is most likely to be the director of nursing, 1.5 LPNs, and 6.5 nurse aides, as compared to a ratio of 1 RN for every 4 patients in a hospital (Mezey, 1992). The median amount of RN time per resident, per day, across all nursing homes in 1985 was 12 minutes or less, and nearly 40 percent of nursing homes reported 6 minutes or less of RN time per resident per day (Jones et al., 1987). Similarly, the American Nurses Association (ANA) found staffing ratios of nursing assistants to patients in intermediate-level care facilities to be 1:11, whereas the ratio for licensed nurses was 1:100 (ANA, 1991). Nursing assistants are the primary care givers in long-term care. Consequently, the care that they provide is an important determinant of the quality of life and quality of care for nursing home residents. The typical NA is a 20- to 40-year-old female; about half are members of a minority group, with low socioeconomic status and a high school education or less. Typically, they are paid little more than the minimum wage. Nurse vacancy rates are higher in nursing homes than in other practice settings. Despite recent improvements (in 1993, 70 percent of state nursing home association executives indicated that vacancy rates in their states had dropped to 10 percent or less) (McKnight's Long-term Care News, 1993), nurses still find hospitals a more attractive setting in which to work. RN salaries in nursing homes are about 15 percent lower than salaries for hospital RNs (Maraldo, 1991). While this situation may have changed somewhat, due to greater concerns about hospital costs in recent years, nursing homes continue to compete poorly for RNs because of wages and working conditions. Unfortunately, caring for the elderly is still not considered prestigious or financially rewarding when compared to other areas of nursing practice. The OBRA 87 regulations contain no staffing standards except that an RN is to be on duty for 8 of the 24 hours each day. Some homes have obtained waivers that permit them to substitute LPNs. Thus, staffing requirements for nursing homes vary from state to state. In Iowa, for example, two hours of nursing care hours per patient day are required for certified Medicaid residents. This breaks down to only about five minutes per hour, even though the average resident who is unable to feed him- or herself requires about one hour of assistance for each

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--> meal provided. If these Medicaid residents who are dependent on receiving help to eat should lose weight continuously over a period of several months, the facility may receive a citation for poor quality care—a real "Catch 22." Some long-term-care providers have successfully sued to become eligible for staffing levels greater than those reimbursed by the Medicaid statute, as was the case with an Atlantic City, New Jersey, nursing home, which argued that the unusual configuration of the facility (three buildings connected by ramps and walkways) required additional Medicaid funds so it could provide adequate staff (McKnight's Long-term Care News, 1993). According to the Select Committee on Aging (1992) in the U.S. House of Representatives, without changes in staffing regulations, the needs of the elderly will remain largely unmet through the year 2020. In their report to the chairman, the committee listed several reasons for a lack of health care personnel trained in geriatrics and gerontology: difficulty recruiting and retaining qualified personnel for direct care in nursing homes, poorly trained workers, little training of family and friend care givers, vague job descriptions, shortages of qualified faculty to teach the needed knowledge and skills to physicians, nurses, and other health professionals, and the lack of appropriate training sites. Clearly, low salaries for nursing home personnel contribute to recruitment and retention problems and low reimbursement rates affect nursing home providers' interest in paying higher salaries. Nature of the Work in Nursing Homes Nursing home work is often difficult, stressful, frustrating, and labor intensive, especially for NAs, who have the most direct contact with residents. Nursing home staff have to confront aging, disability, and dying. Much of the care of the elderly is not pleasant, such as caring for urinary and bowel incontinence or dealing with a cognitively impaired elder who is agitated and combative. Combined with low wages, minimal benefits, hard physical work, and the often progressively deteriorating abilities of the residents, the nature of the work for nursing staff is often characterized as tedious, unpleasant, and unrewarding. Furthermore, because concern for costs is likely to continue while resident acuity increases, the workload of NAs and nurses in nursing homes may very well get heavier. Research related to the actual nature of the work role of NAs documents that the complexity level of most tasks is low (suggesting a routinized approach), and that even when NAs carry out direct care tasks, their attention is not always directed toward residents. The highest level of psychosocial quality interaction was found to occur in the process of socializing, an informal component of care, suggesting the need for alternative task structuring and more resident-centered models of care (Brannon et al., 1992). Other studies support the notion that staff-

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--> to-staff interactions are much more frequent than staff-to-resident interactions (Burgio et al., 1990). In general, RNs in nursing homes suffer from a lack of prestige within the total health care delivery system. They are not only victims of financial disparity, but they are also subjected to humiliation and professional degradation, and their work role is often tied up exclusively with administrative functions. While the reasons are many, the lack of respect for nurses who choose to care for the elderly in nursing homes is at least in part because nurses and other health professionals often share the negative attitudes of society toward the elderly (Harrington, 1984). The work of nursing home personnel is not without rewards, however. These rewards are largely intrinsic and evolve from the relationships formed with the elderly residents and the satisfaction gained from feeling that one has contributed to the quality of their lives, if only in a small way. For some, there are also the rewards of personal development that come from learning about aging and the opportunity to gain clinical skills. Nonetheless, extrinsic rewards for nursing staff remain problematic and this is largely responsible for the frequent turnover of staff and inability to recruit and retain qualified staff. Staff Salaries and Incentives As already mentioned, salaries and other incentives are problematic for all nursing staff in long-term care. One of the major reasons for the dearth of RNs in nursing homes is economic, and retention rates among long-term-care staff have been shown to increase concurrently with increases in average weekly salary. In 1988 they received 88 percent of the typical acute care wage, and by 1990 the percentage had dropped to 86 percent. For RNs, the highest hourly rate was $18.91 in hospitals, followed by $16.82 for home care, and $15.26 for nursing home RNs (Hospital and Healthcare Compensation Service, 1994). Since 1990, there is some evidence that salaries for some staff in nursing homes may be increasing, although they continue to lag behind salaries in hospitals. Annual salaries for Directors of Nursing (DON) were recently reported to have increased by 6 percent to $41,200 (McKnight's Long-term Care News, 1995). The salaries and benefits of nursing assistants, however, provide little incentive and lag behind those for hospital aides and home care aides. The median hourly wage reported by hospital aides was $7.12 between 1987 and 1989, compared to $5.29 for nursing home aides and $4.22 for home care aides. Noting that RNs are a critical component of the rural health care delivery system and in some areas the sole providers of care, the Select Committee on Aging (1992) reported a shortage of 45,382 FTE RNs in nonmetropolitan areas of the United States. The $3,000 discrepancy in annual salary between nurses employed in small hospitals and those employed in large hospitals probably played a role in the shortage (Movassaghi et al., 1992). According to Kayser-Jones (1981b), often the only nurses willing to work for the low wages offered

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--> a need to prepare more nurses with geriatric knowledge to meet the demands for the future, including an increased number of persons from minority groups. All gerontological and geriatric nurses, educators, and clinicians will need to regularly update their knowledge base in gerontology. Adequate compensation for nurses who work with the elderly needs to be assured to provide incentives for increased recruitment and retention of qualified nurses in nursing homes. Advanced information technologies (i.e., fiber optic and digital networks) will increasingly be used in settings remote from educational institutions. Nurses will need to be proficient in the use of such technologies in order to provide care to elders and education to staff. Finally, because geriatric care in the next century will be increasingly interdisciplinary, students from a variety of disciplines should be exposed to interdisciplinary care in their training if they are to be expected to practice in a cooperative, collegial manner. Recommendation 15: Increased funding for gerontological nursing research should be provided by: (1) increasing the number of postdoctoral opportunities in gerontological nursing to prepare future researchers, (2) increasing the level of funding to NINR for gerontological research, (3) encouraging GECs and Centers on Aging to hold geriatric nursing faculty training workshops in grantsmanship and proposal development, and (4) increasing funding for faculty and doctoral student training in gerontological research. Geriatric nursing research has benefited older persons by improving care practices and quality of life, and yet nurses have not fared well in terms of successfully competing for NIH monies in aging-related research. In some cases it is because the quality of the proposals submitted (especially with regard to methodological rigor) is not sufficient to merit consideration for funding. Those gerontological nurse researchers who are fully qualified and produce competitive research proposals are disadvantaged by the disproportionately low level of funding for NINR, which must fund all nursing research, and the competition for limited funds from other NIH agencies. This situation is particularly unfortunate in that the relationship between education, research, and practice should be a dynamic one, with research informing practice and teaching and with more curricula being research driven. Recommendation 16: A provider number for the accountable RN and standardized nursing interventions should be added to the long-term-care minimum data set so that practice pattern variations and outcomes effectiveness can be assessed for specific interventions and nurse providers with MDS data.

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