In April of 2012, the Boston Sunday Globe ran a front page article called, “A Rampant Prescription, A Hidden Peril” by reporters; Kay Lazar and Matt Carroll. The Globe’s analysis of data released by the Centers for Medicare and Medicaid Services found that among other things, “There is a clear link between the rate of antipsychotic use in in a nursing home and its staffing level. Homes that often used these drugs for conditions not recommended by regulators had fewer registered nurses, who direct care, and nurses’ aides who provide most of the hands-on care. Nursing home specialists say it can be more time-consuming for staff to keep dementia patients calm without drugs”.

In addition to the importance of adequate staffing, there are two related elements that make a critical difference, namely the continuity of staff and their ability to build trusting relationships with patients.

It isn’t necessarily an easy task to figure out an exact staffing level of Nurses and LNAs or CNAs (Licensed Nurse Assistants or Certified Nurses’ Assistants) and with budget constraints healthcare leaders have a lot of pressure to run lean. I appreciate this concern and yet believe we are often running too lean and that it compromises patient safety, quality of care and job moral. Further, I believe that one of the easiest ways to assess appropriate staffing is to ask to ask the nurse who is in charge of the unit. Unfortunately, in my experience, this seems to be one of the last resources sought out when making the determination.

The staff nurses and nursing assistants most likely knows the resident, their personalities, behavioral issues, fears, medication regimens, and physical care needs as well as the inter-relationships among the community. Even residents with advanced Alzheimer’s disease seem to get along with some residents and not others, demonstrate differences in introversion and extroversion, and varying interest and abilities in group activities. This is somewhat unique to care on a dementia unit because we don’t just have a certain number of patients to care for. There is also one or more group dynamics to attend to. This is important because if one resident is upset and becomes agitated, this has an impact on others. Sometimes, especially in the late afternoon and early evening when the ‘sundowning‘ effect manifests, this can be a nightmare for residents and staff alike.

So how many nurses and nurses’ assistants do we need?

Enough.

At least most of the time, enough to ensure:

that there is someone available to answer call bells and alarms right away.

that there is an extra pair of hands available to help transfer, turn, dress, and bath residents whenever needed.

that the nurse is available to answer questions from staff, patients, families etc.

that residents who are able to walk with assistance are assisted as necessary.

that the assistants and nurse don’t have to rush residents to eat, drink, take the medications, or any other activity.

that the nurse has time to assess a sick resident and communicate with the physician and document according to protocols.

that the staff is taking meal and rest breaks according to human needs, legal regulations, and organizational parameters.

that when a conflict arises among staff there is time (and expertise) to facilitate productive outcomes.

Bridging the gap between budget and staffing requires open and honest dialogue among staff, middle managers, and senior leaders. Nurses must be able to delegate to responsive team members, managers must be willing to advocate for resources and set limits, and leaders must be willing to provide enough qualified staff to do the work. At least most of the time!

Why is Continuity Important?

The relationships between patients and staff and between staff are hard to measure and very important. This is true in most nurse practice settings and especially crucial on a dementia unit. Residents in such a community are still able to develop a sense of trust and familiarity with there caregivers. Caregivers gain a sense of who likes a back rub, who might be fearful of a shower, what someone’s favorite drink or snack is, who can stand and pivot. There is a false sense of thinking that all important information about care gets recorded care plan and is updated, reviewed, and followed. Not because care plans aren’t respected, but because we often don’t have time to read them and there are many details about providing care that can get lost while we are focusing on the most critical of needs. Ironically, missing details will often lead to much more critical problems and more expensive intervention. A counterproductive and potentially unsafe cycle.

Here are a couple of examples:

A resident who is lactose intolerant receives a cup of ice-cream, has diarrhea, ends up with skin break-down, fails to heal, has skin ulcer which worsens.

A resident who has no ability to ‘push’ in order to have a bowel movement and requires an opportunity to sit on a toilet or commode for 20-30 min in addition to her bowel medications, staff don’t know or don’t have time to get her on the commode and monitor, she becomes impacted and ends up in the emergency room because of severe pain.

When we see these end results, it is easy to blame staff for negligence, when elements of staffing remain invisible. Most nursing home officials don’t want to be the next case on the desk of an accident attorney in Fresno.

Continuity also impacts teamwork.

It is a fundamental principle of group dynamics and team development that changing the membership of a team requires the stages of group development, (Bruce Tuckman’s Stages of Group Development) to start all over again. With constantly changing team members, this becomes impossible to facilitate and manage. Resentments and conflicts linger and abilities to learn and grow from each others’ differences are lost in a world of blame. Granted, consistent team membership has special challenges in a 24/7/365 operation, yet we can and should include this concept in our staffing decisions and team-building efforts.

What About Emotional Intelligence?

An ability to read other peoples emotional energy, body language, non-verbal communication and self awareness are skills associated with Emotional Intelligence. I’m convinced that most folks with dementia are learning to trust us even if we can’t measure, prove or bill for it! The other day I saw an elderly woman who doesn’t speak, is very contracted and confined to a reclining chair or bed lean forward and kiss the nurse’s assistant on the cheek who had just given her a bed bath and gotten her dressed. Another nurse’s assistant recently sat with a resident to welcome him back from a period in an acute psychiatric facility. He smiled. A rare occurrence! One more example is the assistant who stopped for a moment to dance with a resident when there was music playing and she was walking by and noticed the resident moving in rhythm. The resident, for a few moments was engaged and happy. These 3 nurses’ assistants are VERY different, yet all caring individuals and the residents, on some level feel safe and trusting.

I have many more examples of glimpses of cost-saving and quality-providing care given by hardworking and skilled nurses and nurse assistants. Yet sadly, I hear them blaming each other, “he’s too slow”, “she talks too much”, “he’s too bossy”. In my opinion, this is a symptom of a toxic work culture more than a reflection of the individual assistants.

All in all, staffing for safe, quality, cost-effective and compassionate care is complicated and the more we can nurture difference, respect team development, and promote effective communication, the more successful we will be! This won’t eliminate the need to medicate patients for behaviors, but it will go a long ways to minimize it.