Catherine B. Skinner

Never wanting to be considered part of the hospitality industry hinders analysis of complex problems in our extremely regulated industry. Plain and simple.

Nursing homes are also in the second-most highly regulated industries — the first reportedly being nuclear energy and NASA, and they are staffed with master’s degree-level employees. In the nursing home industry, a large part of the country requires only a GED-level educational certificate and a two-week class to become a certified nursing aide.

Most American nursing homes are for-profit. Since most have a resident population funded by Medicare and/or Medicaid, private-pay residents are few. Hence, this industry is being funded by taxpayer dollars. That’s a given.

But nursing homes are part of the hospitality industry. Only hospitality economics apply. We have no inventory. Our product is consumed as it is created. This is the sum total of why the industry is so difficult. In fact, on any given day, the administrator has no guarantee how many will come through the front door or go through the back door. Nursing homes are also in the group of second most-regulated industries in this country — supposedly right after nuclear energy.

In our industry, large parts of the country require only a GED or high school equivalent degree and two weeks of training to become a certified nursing aide. Yet we recognize that today’s nursing home population is similar in acuity to the hospital patients of the 1980s, when registered nurses cared for them. There is a disconnect here.

Add to this the current demographics of an aging population, and the fact that a major cohort of practicing nurses are soon to retire and be replaced … by what?  We don’t know. Women today simply have other career options more compatible with family life. Not only is there a continent-wide shortage of nurses — no more recruiting from Canada — but the demographics of the nursing homes have been changing over the past decade. More veterans are seeking admission with complex needs, both physical and mental. Add to this the lack of group homes for mentally retarded/developmentally disabled people, especially in rural areas, and, hence, they too are being admitted. The needs of these two groups were never part of any nursing or CNA class.

The cost of orientation is high in this revolving-door industry. What meaningful measures can management have implemented to stem the flow? Little! You promise competitive wages, but little else. Poor coverage of health insurance, “written in stone” schedules, making continuing education nearly impossible. Look at your lunch room. They lack basics: purse lockers, coat hooks … there are ratty old chairs and an ancient fridge. And the nurses’ work areas … a tiny med room, office chairs with raggedy arms (a potential infection control issue?). The desk areas are designed for long ago discarded equipment and systems. A time-wasting setting for busy nurses, doing complex work.

How many of your nurse, including CNAs, bring a bag of equipment with them because the house equipment can’t be relied on? All this creates an inefficient and hostile work environment. Chairs and equipment are  simply a “cost of doing business.” Many homes will even go to the extreme of trying to ignore International Nurses Week … ”no budget” to recognize the country’s most trusted profession. Sad!

Many DONs do not recognize the value / need for a degree. That shows you have hired the wrong nurses. An AD nurse is considered a technical nurse, focusing on care. There is little time in a two-year course to focus on management or leadership — the focus of a DON. The BSN holder takes the time to develop a nurse’s leadership and management skills, and roles needing these skills. The role of DON is “above the pay grade” of the AD nurse. And when the AD degree nurse sees no value in a BSN, she lacks enough pieces of the puzzle to see that value. Sad.

Each admission is supposed to be overseen by an RN. All the forms with the heading “assessment” are to be completed by an RN, yet so many places allow an LPN  to complete them. A one-year course does not prepare a nurse to do a quality assessment. And state boards indicate that assessments are to be completed by RNs. And while on the topic of assessments, many of these forms were devised decades  ago without updates. Hence, they are no longer accurate in what they attempt to rate.

The administrator cannot be overlooked for his/her role in the high turnover,  leadership/management mix. Healthcare is described as a “middle-class” culture, where most of the staff have a college education — on a level playing field. In states that allow only “trained” administrators, there is no level playing field. A Pentecostal DON was asked to wear make-up, while in some places only shapely young DONs are known to be hired. Unacceptable.

CNAs are the worker bees of any nursing home, of course, yet many of the training schools charge a very high tuition. And even worse, in rural areas, it is hard to find a class when one is needed. If a home gets a poor survey and fined a certain amount, it is denied the chance to hold a class. Yet they are the very homes that needs it most. This vicious cycle of poor survey and class denial needs to change or care will not improve. The passing of legislation to allow the teaching in these homes needs to be passed, and fast.

How many homes bypass medical records professionals? In over a quarter century I have never worked in a home with a medical records professional. It is always an LPN in the office labelled “medical records,” yet nothing in her one year of schooling prepared her for this role. If a nurse cannot work as an X-ray tech, how can an LPN be given a medical records job? Easy answer. When a med-nurse calls in, she becomes the back-up med nurse –that simple.

Might you be too near the forest to see these trees? Of course you are. It is a very complex forest.

Cynthia Skinner is a long-time skilled nursing nurse, who has practiced in various parts of the U.S. and Canada. She currently works in Arkansas.