Staffing to Avoid Deficiencies.

Can various aspects of staffing lead to serious deficiencies and subsequent enforcement actions? We know, in fact, that they can, with deficiencies including P353-Sufficient Nursing Staffing; F224-Neglect; and F309-Necessary Care and Services. Staffing problems can lead indirectly to survey citations, as well--from F314-Pressure Ulcers; F325-Nutrition; and F327-Hydration to F241-Dignity; F282-Qualified Persons; and F441-Infection Control. What can administrators and directors of nursing do about staffing to prevent these deficiencies?

Staffing problems include: (1) too few staff to deliver adequate care; (2) too many new or temporary agency staff who do not know residents very well; (3) staff who have not received adequate training in caring for residents' special needs; (4) staff who are not scheduled or deployed effectively by managers; (5) staff who are not integrally involved in resident care plan changes; or (6) staff who are not resident-centered in their care-giving approaches. Let's analyze each problem in turn and determine leadership strategies to prevent and solve the underlying root causes.

First, every nursing home manager knows how hard it is to attract and retain sufficient numbers or staff, partly because of general economic conditions and partly because of staff perceptions of work in the nursing home setting. I don't think that we can personally control the unemployment rate locally or nationally, so let's concentrate on improving staff perceptions of nursing homework. Managers cannot alter the essential duties of nursing staff, nor the importance of delivering high-quality resident care. However, managers can strive to create a workplace that attracts high-quality staff who, in turn, are more likely to deliver such care. Past columns in this publication have described characteristics of and strategies to achieve a high-quality workplace. The most successfully staffed nursing homes have leaders who understand the needs of their workforce and provide them with flexibility, autonomy and support. Most importantly, these nursing homes offer staff the "three Rs": respect, recognition and rewards.

Second, as noted, having large numbers of brand-new staff or using high numbers of temporary agency staff make it unlikely that resident care needs will be met in a knowledgeable, skillful or consistent manner. New staff do not yet know the individual preferences of residents, such as who likes to take a bath at night, who needs to be approached quietly or who will eat what favorite food. Temporary staff will, of course, be similarly uninformed. Successful nursing home managers schedule the introduction of new nursing staff gradually to minimize the disruptive effect on residents and will avoid over-reliance on temporary nursing staff. Most importantly, these nursing home managers "pull out all the stops" to retain the high-quality staff they already have.

Third, having staff who do not know how to care for residents' special needs often indicates a lack of leadership commitment to ongoing education. In tough financial times, it is frequently the inservice education budget that suffers first. Some managers eliminate a dedicated position, cram education-related duties into another nurse manager's job description or assume that education will magically happen without time, money or attention. If staff do not know how to perform effective restorative nursing techniques, then residents are likely to experience declines in range of motion and activities of daily living. If staff do not know how to help residents eat, then residents will likely lose weight and might even develop pressure sores. If staff do not know how to position residents safely or perform transfers from bed to chair, then residents might experience falls, injuries, skin tears and bruises. Top-notch nursing home managers make time for, dedicate resources to and pay attention to staff education nee ds.

Fourth, nursing home managers who fail to schedule and deploy nursing staff effectively might actually be contributing to staff turnover and poor morale. If staff schedules are not developed with employee input and with recognition that employees must attend to their own life needs, then the facility will likely experience a predictably high rate of "no call, no shows" and last-minute call-offs. If staff-resident ratios or per patient day (PPD) levels are not periodically adjusted for residents' acuity and cognitive changes, then staff assignments might become overwhelming and unrealistic. Successful nursing homes create logical, predictable and workable schedules for staff. Most importantly, good nursing home managers carefully listen and respond to staff feedback about work assignments.

Fifth, having staff who do not participate in, know about or keep up with changes in residents' care plans virtually guarantees poor quality of care. Residents' conditions do not stay the same; their ADL performance might deteriorate, their cognitive status might fluctuate, and their needs and preferences might change throughout the course of their stay. If nursing staff are not welcomed at resident care conferences, then subtle changes in residents' conditions might not be identified, and new care approaches might not be carried out in a timely fashion. Successful nursing homes invite nursing staff to be involved in the assessment and care planning processes, not just the care delivery process. Most importantly, the best nursing homes create a continuous, seamless process of care that involves all staff from beginning to end.

Sixth, if nursing staff are more concerned about facility policies than resident needs, the quality of care provided to residents inevitably suffers. House policies are only effective if they allow for flexibility to meet the needs of all residents in the house. Nursing homes managers should evaluate whether their workplace culture emphasizes staff compliance or, rather, puts residents' needs first. Successful nursing homes understand that meeting residents' needs is the ultimate measure of high-quality care. Most importantly, happy, productive staff tend to deliver high-quality, resident-centered care.

A final note about staffing issues. Many of you have probably read at least the Executive Summary of HCFA's three-volume staffing study by now. This report discusses conclusions from Phase 1 of a multiyear study. It does not recommend staffing ratios (yet)! However, Phase 2 of HCFA's study, including a potential recommendation for staffing ratios, will likely be published by January 2001, and several congressional representatives are already preparing legislation that proposes to institute mandatory minimum staffing ratios nationwide. Let's demonstrate that we are capable of solving the complex problem of adequate staffing ourselves--and fast, before the federal government attempts to solve the problem for us.

Beth A. Klitch, FACHCA, is president of Survey Solutions, Inc., Columbus, Ohio.