The use of contract agency staff to fill nurse aide and licensed nurse vacancies is escalating. Does that surprise you? Although the proportions of nursing staff comprising contract agency staff are still small, it has almost doubled in some states over the last two years.
We recently analyzed contract staff utilization in the state of Massachusetts over the past two years and here is what we found: The proportion of licensed Nurse hours per resident day (HPRD) provided by contract agency staff soared from 0.9% in 2014 to 2.1% in 2016, and nurse aide HPRD increased from 0.6% to 1.4% of the total hours reported.
This increase is seen across many states, not to mention across the nation as a whole. Yes, we have a well-documented nursing shortage. Who, if anyone, is concerned? Let’s all take a number and get in line!
Contract staff utilization is not inherently a bad thing. In fact, for some very qualified CNAs and nurses, life’s circumstances make agency work more palatable. Some organizations actively recruit contract staff and like the “try before you buy” approach, knowing the hassles of recruiting and retaining staff.
However, the use of contract CNAs is associated with more professional liability claims, allegations and actual losses, along with adverse outcomes such as falls and new or worsened pressure ulcers.
Is the contract CNA’s knowledge on how to prevent these outcomes lacking? Or do they not know the residents well enough? If best efforts to fill vacancies fail, then care should be taken to ensure your contract agency is adequately vetting their staff, and in turn, you provide the appropriate oversight and supervision.
The consequence of contracted licensed staff is more complicated. In our study, contracted licensed staffing, per se, was not associated with negative outcomes, but rather the relationship it has to other variables.
What appeared to have the greater risk than contract license staff alone are a low RN-to-today licensed ratio and indirect care proportion <10%. If you have a lot of bedside nurses but just one full-time director of nursing, and no nurse educators or advanced practice nurses and ADONs mainly doing direct care, there is not enough indirect care to address nursing staff supervision, trainings and coordination. Proper supervision, education and coordination are critical for both employed and contracted nurses.
The new Requirements of Participation add to the challenge. In phase two (Facility Assessment) you must ensure residents’ needs can be addressed by the competencies of your staff. Consider how this might impact how you interact with your contract staff agency, and staff.
Increased contract/agency staffing use might be in all our futures. Planning for careful integration into your current operations is definitely in order.
Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.