Staff development: the neglected discipline.

How many times following the department of health survey have you sat down to write your facility's plan of correction and noticed yourself writing that all too familiar phase "facility staff will be [or have been] in-serviced on ..."? The frequency with which this phrase appears in the responses to deficiencies reported on the CMS-2567 implies that most deficiencies received during the annual survey resulted from a lack of staff knowledge. If we are to assume that this is true, one should ask the logical question: Why wasn't education provided to staff in the first place? And that question should immediately give rise to another question: Why weren't these educational needs identified and addressed before the department of health survey?

It has been said that philosophy and staff development share the commonality that neither discipline "bakes any bread," that is, neither contribute directly to the bottom line. According to some nursing home administrators (NHAs), not only does staff development not "bake bread," it "costs bread." It is sometimes hard for the NHA to see the tangible results of the staff development department because staff education is not a directly billable service, like therapy. Nor is staff education able to be "captured" on the Minimum Data Set (MDS) for increased rates of reimbursement.

Having a full-time staff development professional in long-term care is often viewed as a "luxury" or something that's "nice but not necessary." In an attempt to save money in the years following the implementation of the Medicare Prospective Payment System (PPS), many skilled nursing facilities eliminated the staff development role, or reduced it to a "part-time" position. Those facilities that eliminated the role completely added the responsibility for staff development to the already long list of duties assigned to the Director of Nursing. While this idea appeared to save facilities money in the short term, it may be resulting in additional costs in the long run.

This article will explore how lack of a staff development department has the potential to negatively affect skilled nursing facilities (SNFs) in a multiplicity of ways--and what to do about it.

Federal Regulations Specific to Staff Development

Two federal regulations are immediately applicable to staff development: F-tag 497 and F-tag 498 (see sidebar, p. 34). Other regulations deal with requirements for nurse aide training and still others are indirectly related to staff development, but for the purpose of this discussion we will focus only on these two regulations. Most skilled nursing facility administrators are aware of the existence of these regulations, but many are not aware of their complete content and consequences.

When a surveyor has concerns specific to nurse aide performance, the regulations provide specific guidance to the surveyor to assist him or her in evaluating the facility's training and development programming. In the "guidance to surveyors" section of F497, it is pointed out that educational activities should be conducted to address areas of weakness, as determined in the nurse aide's annual performance review.

The facility administrator should be aware of both of these regulations and be certain that a mechanism exists within the organization that translates identified areas of nurse aide performance "weakness" into educational activities and subsequent competency evaluation. Who in your facility is doing this?

Impact on Staff Turnover

One study estimated that the cost of employee turnover can climb to 150% of the employee's annual total compensation. (1) Bales et al, as cited in Parsons et al, concluded that poor job orientation and training influence nursing assistants' desire to leave skilled nursing facilities. (2) Perhaps some of the problems associated with nursing assistant turnover can be addressed through the efforts of an effective staff development program.

Impact on Clinical Reimbursement

In addition to regulatory compliance and employee retention, appropriately conducted staff education can translate into higher reimbursement through proper coding of the MDS 2.0. Section G of the MDS includes items termed "late-loss" activities of daily living (ADLs), including bed mobility, transfer, eating, and toileting. These items account for 30% of items used to calculate the RUG-III score. Appropriate initial and ongoing education is needed for all staff members responsible for completing the supporting documentation specific to these MDS items. Still other areas, such as mood, skin assessment, time awake, nutrition, and special treatments and procedures, are responsible for determining RUG-III classification. Those staff members responsible for completing these MDS items require ongoing education, competency validation, and support to ensure that these items are accurately documented in the resident's clinical record and subsequently captured on the MDS 2.0. Training in these areas is essential to provide the interdisciplinary team with a true picture of resident care needs and maximize reimbursement.

Impact on Quality of Care

Although the MDS is best known as an instrument that sets the reimbursement rate for residents in skilled nursing facilities, the instrument's original purpose was to improve quality of care in skilled nursing facilities through comprehensive assessment and care planning. (3) Through ongoing education, coaching, and mentoring, an effective staff development department can provide instruction to nursing staff relative to the requirements of long-term care, as well as principles and best practices in gerontological nursing.

The literature offers multiple examples of how staff education can be used to enhance residents' quality of life. Crogan and Evans concluded that nursing assistants can benefit from one-on-one instruction to enhance the mealtime experience for residents. (4) Programs such as this have the potential to prevent deficiencies at F326. Williams et al found that effective training programs reduced the incidence of inappropriate communications by nursing assistants and resulted in more caring communication between nursing assistants and residents (thus helping avoid deficiencies at F224 and F241). (5)

Selecting the "Right" Staff Development Professional

Staff development refers to a myriad of formal and informal educational activities that support all levels of SNF employees. O'Shea contends that "gone are the days when an aging nurse with excellent bedside skills becomes the 'in-service nurse.'" (6) Staff development is a nursing specialty recognized by the American Nurses Credentialing Center (ANCC), which offers certification in "nursing professional development" (formerly called "nursing staff development"). The administrator must consider the importance of this role and select the right professional to assume the essential duties of this department.

Some authors contend that a graduate degree is a necessary prerequisite for the staff development position. (7) Although a master's-prepared nurse would be beneficial in many respects (especially preparation in gerontological nursing), a nurse prepared at the graduate level is not necessarily needed in the long-term care setting. One should never depend on credentials alone to determine the worthiness of a would-be staff development professional in any setting.

Emphasis, instead, should be placed on recruiting an individual who has a firm knowledge of long-term care rules and regulations, has demonstrated some degree of clinical competence and successful experience in long-term care, and has both leadership and "people" skills. It is essential to remember that just because someone is a good clinician, this does not necessarily mean that he or she will be an effective educator.

Ask the candidate about his or her experience in providing educational offerings in the past. Ask candidates about their plans for their own professional development as they look toward the future. Explore each candidate's sense of initiative. What has the individual done to demonstrate that he or she is a self-starter? Ask them about knowledge of updates to the long-term care survey process or recent amendments to the MDS/RAI. While you are not looking for the individual to be expert in all of these areas, you are assessing his or her initiative in keeping current with the changes that affect long-term care. The staff development professional that you select should demonstrate initiative in researching and developing courses, as he or she will be working independently much of the time.

Explore the candidate's knowledge, skills, and abilities in gerontological nursing. Gerontological nursing is also a specialty area recognized by the ANCC, which offers certification in "gerontological nursing." If you cannot find a candidate who holds current certification in gerontological nursing, examine the candidate's resume in terms of experience with providing care to older adults as well as continuing education specific to gerontological nursing. If your staff development professional lacks knowledge about older adults, it is highly unlikely that he or she will be successful in terms of enhancing your staff's ability to provide appropriate care to your residents.

Consider the candidate's organizational skills. The staff development role often involves juggling multiple responsibilities, including new employee orientation, annual competency testing (which should be done on all high-risk procedures), annual in-services, remedial education programs, nurse aide training programs, and individual mentoring and coaching for employees who have performance difficulties.

Provide your new staff development director with the tools that he or she needs to do the job. This should include a comprehensive orientation program, as well as a thoughtful orientation specific to those departments with whom staff will interface on a routine basis (human resources, for example). Finally, encourage and support the staff development person's networking through professional organizations, such as local consortiums for staff development professionals, or through membership in the National Nursing Staff Development Organization.

By investing in your facility's staff education department, you show your staff and residents that you are committed to providing the highest quality of care possible by providing them with ongoing education, mentoring, coaching, and support.

Timothy J. Legg, PhD, GNP, RN-BC, NHA, FACHCA, is a Senior Consultant with Gerber Consulting Services, Inc., Clymer, Pennsylvania. He is also Assistant Professor of Health Sciences at Touro University International, Cypress, California. Dr. Legg is a Commonwealth of Pennsylvania-approved directed in-service provider and is certified in both nursing professional development and as a gerontological nurse practitioner through the American Nurses Credentialing Center (ANCC). For further information, phone [phone] or visit www.gerberconsulting.com. To send your comments to the author and editors, please e-mail [e-mail].

References

1. Contino DS. How to slash costly turnover. Nursing Management 2002;33(2):10,12-13.

2. Parsons SK, Simmons WP, Penn K, Furlough M. Determinants of satisfaction and turnover among nursing assistants. The results of a statewide survey. Journal of Gerontological Nursing 2003;29(3):51-8.

3. Popejoy LL, Rantz MJ, Conn V, et al. Improving quality of care in nursing facilities. Gerontological clinical nurse specialist as research nurse consultant. Journal of Gerontological Nursing 2000;26(4):6-13.

4. Crogan NL, Evans, BC. Nutrition education for nursing assistants: An important strategy to improve long-term care. Journal of Continuing Education in Nursing 2001;32(5):216-18.

5. Williams K, Kemper S, Hummert ML. Enhancing communication with older adults: Overcoming elderspeak. Journal of Gerontological Nursing 2004;30(10):17-25.

6. O'Shea KL, ed. Staff Development Nursing Secrets. Philadelphia: Hanley & Belfus, 2002.

7. Abruzzese RS, ed. Nursing Staff Development: Strategies for Success. 2nd ed. St. Louis, Mo.: Mosby, 1996.

8. Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP--Guidance to Surveyors for Long Term Care Facilities, Rev. 22, December 15, 2006. Available at: http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf.

by Timothy J. Legg, PhD, GNP, RN-BC, NHA, FACHCA

RELATED ARTICLE: F-Tags 497 and 498 (8)

F497

[section]483.75(e)(8) Regular In-Service Education The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. The in-service training must--

(i) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year;

(ii) Address areas of weakness as determined in nurse aides' performance reviews and may address the special needs of residents as determined by the facility staff; and

(iii) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.

Interpretive Guidelines: [section]483.75(e)(8)

The adequacy of the in-service education program is measured not only by documentation of hours of completed in-service education, but also by demonstrated competencies of nurse aide staff in consistently applying the interventions necessary to meet residents' needs.

If there has been deficient care practices identified during Phase 1 of the survey, review as appropriate training received by nurse aides in that corresponding subject area.

For example, if the facility has deficiencies in infection control, review the infection control unit in the facility's in-service nurse aide training program.

Each nurse aide must have no less than twelve hours of in-service education per year. Calculate the date by which a nurse aide must receive annual in-service education by the employment date rather than the calendar year.

Probes: [section]483.75(e)(8)

During an extended or partial extended survey, or during any survey in which nurse aide performance is questioned. (See [section]483.75(f).)

* Does the facility review the performance of its nurse aides?

* How has in-service education addressed areas of weakness identified in performance reviews, special resident needs, and needs of residents with cognitive impairments?

* How has in-service education addressed quality of care problems including those of special care needs and resident rights?

F498

[section]483.75(f) Proficiency of Nurse Aides The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Interpretive Guidelines: [section]483.75(f)

"Competency in skills and techniques necessary to care for residents' needs" includes competencies in areas such as communication and personal skills, basic nursing skills, personal care skills, mental health and social service needs, basic restorative services and resident rights.

Procedures: [section]483.75(f)

During the Resident Review, observe nurse aides.

Probes: [section]483.75(f)

Do nurse aides show competency in skills necessary to:

* Maintain or improve the resident's independent functioning, e.g.:

** Performing range of motion exercises,

** Assisting the resident to transfer from the bed to a wheelchair,

** Reinforcing appropriate developmental behavior for persons with MR, or

** Psychotherapeutic behavior for persons with MI;

* Observe and describe resident behavior and status and report to charge nurse;

* Follow instructions; and

* Carry out appropriate infection control precautions and safety procedures.