Essential staffing for improved nursing home care: the permanent assignment model.

Nursing aides are a significant component in the provision of care for persons residing in nursing homes. They assist residents with bathing, using the bathroom, grooming, dressing, eating, and mobility. Aides also provide emotional support, acting as a "human" link in the chain between care services and residents. Due to the scope and depth of their involvement with patients, aides can be an important and highly valuable component of any nursing home.

The way they are used impacts upon the makings of a quality facility. Specifically, the structure of nursing aides' jobs can dramatically affect the efficiency and quality of care which they provide. Most nursing homes and long-term care facilities employ the rotation model in assigning duties to aides. This rotation system is a staffing pattern which involves the assignment of aides to work with different patients during different time periods (each day, week, pay period, etc.). Thus, residents constantly have different aides working with them and there is no consistency in the staffing pattern except that changes do occur, and occur frequently. An alternative to rotation is the permanent assignment model. It involves strategically assigning nursing aides to specific patients, whom they work with each day on a permanent basis. Residents have the same aides working with them and they know who "their aide" is. Only when their assigned aide is off duty do they have a different aide.

The permanent assignment model is derived from standard hospital practice, which assigns professional nurses to a specific patient caseload for the duration of their hospital stay. Prior to World War II, nurses were the primary caregiver to the patients. This role of the nurse broke down during the war, when instead, teams were implemented to serve large numbers of individuals because of efficiency considerations. After the war, this practice was furthered by the view that health care organizations were part of any industry where each person's job should be both routine, and specialized. Later, however, many hospitals moved to primary nursing where a nurse was assigned to each patient and was responsible for the patient from admission through discharge.

The underlying philosophy behind rotation depicts patients as persons to be serviced. The treatment and care given to residents can be viewed (due to specialization and routinization) as standardized care where each aide addresses specific aspects of care. The rotation model tends to increase the standardization of care, which deters aides from providing holistic care and becoming personally involved with, and vested in, their duties.

In contrast to rotation, the objective of the permanent assignment model is to maximize the quality of services by personalizing them for each resident. By permanently assigning nursing aides to specific residents, commitment is increased by instilling a sense of "ownership" or personal responsibility to the aides for the care of "their" residents. Permanent assignment also enhances the relationship between the facility and the resident with the aide being a liaison who has a vested, personal interest in the well-being of the resident. By forming this type of in-depth relationship, aides become more aware of the individual needs of each resident. They gain the incentive of making better use of their own creativity and resources to best accommodate the needs of each resident, thus reducing standardization and increasing individualization.

The permanent assignment model has proven to be effective for improving the quality of care provided within long term care facilities. A study was conducted to test the effectiveness of this model implementation at two nursing homes. Both nursing homes were licensed skilled care facilities and both provided skilled and intermediate care. One facility had a total of 100 beds and the other 60. Permanent assignment was implemented at both facilities for a three-month time period. The study examined the impact of permanent assignment of aide's attitudes toward both the model and the residents; the quality of care given by the aides; the aide's job satisfaction, turnover, and absenteeism; the resident's and families' feelings about the model; and the resident's attainment of their care plan goals.

Under the permanent assignment model, the overall quality of care provided by the aides to the nursing home residents showed significant improvement. Aides reported that they were in a unique position of being able to develop reciprocal, caring relationships with the resident. They became more aware of the patients' needs and concerns, and thus, were able to provide more personalized and efficient care. They showed more attention to their residents and were more concerned about their progress. This model also allowed the aides to devote more time to work with their residents on performing various tasks such as socializing, taking walks, engaging in recreational activities, etc.

With the permanent assignment model, aides developed a sense of ownership and commitment toward their patients due to their involvement and concern. The aides also developed more of a vested interest in the rehabilitation of their residents, as well as higher expectations with regards to each of their abilities. As a result, the aides became keenly aware of progress residents had made, and also expressed pride and accomplishment with the results of both the residents, and their own efforts towards the attainment of specific goals. In addition, permanent assignment fostered a natural competitiveness among the aides. As primary caregivers to their particular residents, the aides felt more responsible and accountable for their residents' overall care, thus, it is understandable that the aides wanted to see their residents better groomed and functioning better than another aide's residents.

The permanent assignment model also diminished the frequency of behavior problems exhibited by the residents. Residents were found to be much more cooperative, pleasant in attitude, and increasingly responsive to care providers. Specifically, incidents of behavior management problems such as physical aggression, verbal abuse, purposely resisting treatment, and breaking the rules were significantly reduced. This resultant benefit may be attributed to the positively enhanced relationship between the aides and the residents. In addition to a general improvement in behavior, residents felt more comfortable and secure in the nursing home environment. The continuity of care helped create a sense of well-being in the residents because they knew that their needs would indeed be met.

Finally, the permanent assignment model had a significant effect on the aides' turnover and absenteeism. During the time which this model was implemented, the average turnover rate and the average number of aides absences were much lower when compared to aides who rotated. As mentioned previously, permanently assigning the aides created a sense of commitment to the residents. The responsibility and concern among the aides toward their residents had generalized to their job as a whole. From an administrative standpoint, the implementation of this model could very well lessen the overall cost of operations, and save on the time needed to constantly hire and retrain staff.

Once the administration has committed itself toward implementing the model, the next step is to gain the commitment of the nursing aides for the project. Due to their key involvement with residents, it is essential to involve the aides in much of the planning process. Give the aides opportunities to voice concerns and to provide input pertaining to the overall project. Initially, aides may be apprehensive regarding the model's potential and their involvement in it. Concerns include the fairness and balance of patient assignments, the potential boredom of working with the same group of residents on a continuous basis, lack of assistance when needed, etc. Additionally, some aides may fear that both they, and their patients could become too emotionally attached to one another.

Taking into consideration the aides' concerns regarding the fairness of patient assignments, residents should be divided into groups according to the amount of care they require in an effort to evenly distribute the "heavy" and "easy" care residents among the aides. Thus, an equal distribution of work among the aides would be guaranteed. These groups can then be matched to lists which the aides make, consisting of residents they would like to be permanently assigned to. Aides can then be assigned to work with the group of residents that most closely matched their preference list.

Throughout the implementation of this model, meetings between the aides and their supervisors are necessary in order to facilitate communication. Offering aides the opportunity to provide important feedback and to discuss their expectations and experiences will increase the likelihood of successful implementation. In addition, such meetings serve as a means to address the various concerns and misconceptions associated with this new staffing pattern and also will help to further incorporate the aides as an important component of the overall planning process.

In summary, the benefits derived from the permanent assignment model are multifaceted. The overall quality of care, the performance and attitudes of the aides, and the residents' progress and satisfaction with care were enhanced. The nursing home residents received more attention from the aides, and a higher quality of care. They were also more cooperative and engaged in fewer behavior problems. The aides felt a greater sense of commitment to their jobs and to their patients. Because of the increased efficiency of the aides this model also allowed the aides more opportunities for meeting the resident's social, leisure, and rehabilitative needs. This individualized approach to caregiving has proven beneficial, efficient and effective.

Bibliography

Cheren CE. Permanent team assignments: quality care that makes good sense. Nursing Homes 1983 (July/Aug.); 22-24.

Patchner MA. Permanent assignment: a better recipe for staffing of aides, in Day JM, Berman HJ (eds): Successful Nurse Aide Management in Nursing Homes. Phoenix, The Oryx Press, 1989; 50-58.

Patchner MA, Taber MA. Permanent Assignment of Aides to Nursing Home Residents. School of Social Work, University of Illinois at Urbana-Champaign, Urbana, IL, 1986.

MICHAEL A. PATCHNER, PH.D., Dean and Professor, West Virginia University, School of Social Work, 708 Allen Hall, Morgantown, WV 26506

LISA S. PATCHNER, M.S.W., Nursing Home Consultant and Adjunct Instructor, West Virginia University, School of Social Work, 968 Southpoint Circle, Morgantown, WV 26505