Nurses working together in hospital
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While the long-term care sector braces for the announcement of a final nursing home staffing mandate from the Centers for Medicare & Medicaid Services, new analysis suggests that optimizing the role of registered nurses would be an even more effective way of increasing quality of care.

Care quality would strongly benefit from an industry-wide focus on the responsibilities of RNs, the study’s authors said. Specifically, leaders should more actively differentiate RNs from licensed practical nurses, use a nursing practice model framework to maximize the role of RNs and provide RNs with more education in leadership and geriatric care.

“Although the number or HPRD [hours per resident day] of RNs is important,” the researchers wrote, “what is even more essential is leveraging the full scope of practice and accountability of the RN to impact organizational, resident and staff outcomes.”

These recommendations could help address the gulf between care providers who argue that the staffing mandate is dangerous to nursing homes’ ability to continue to operate and consumer advocates who often argue that the mandate does not go far enough to improve care outcomes, the authors suggested.

Both staffing increases and better use of RNs are crucial to achieving the highest care quality, stressed lead author Christine A. Mueller, PhD, RN, a professor at the University of Minnesota’s School of Nursing.

“It is a ‘both/and,’” she told McKnight’s Monday. “Staffing standards need to be increased, and strengthening and leveraging the role of the RN in nursing homes needs attention.”

The study was published Friday in the Journal of the American Geriatrics Society.

Changing the framework

Optimizing RNs’ work will require intentional strategy shifting, the authors explained.

“For many nursing homes, this will be an organizational culture change,” Mueller said. “It will require leadership, especially the director of nursing, to re-envision the role of licensed nurses and the care delivery structures and processes — specifically how nursing care is organized and delivered.”

The study referenced previous research showing many RNs are bogged down with administrative tasks while LPNs are asked to do work beyond their scope, doing tasks that would be better handled by RNs. In some cases, directors of nursing are either uninformed or unable to differentiate between RNs and LPNs in daily activities. This muddling of the two roles can lead to less efficient and less expert care for residents, the authors said.

A solution could be switching from the common “task lens” framework to a more modern nursing practice model framework of care that prioritizes using RNs as geriatric care experts, mentors of unlicensed nursing staff, and coordinators responsible for ensuring the continuity of care performed by LPNs and certified nursing assistants, researchers said. 

This model would ensure that RNs are more consistently responsible for the complex care needed by so many long-term care residents, and it also would provide LPNs and CNAs with expert oversight and mentorship.

Specialized education

Such a model differentiating and maximizing RNs would require changes to how RNs are educated as well. The nursing practice model requires nursing home RNs to be experts in geriatric care subjects and trained as leaders and mentors. These areas are sometimes lacking in current education programs, the authors said.

“A national reassessment of current curriculum integration of gerontological nursing is long overdue,” they wrote, also noting that most nursing programs only have one course focusing on leadership skills.

These gaps could be closed by creating more partnerships between nursing homes and nursing schools, Mueller told McKnight’s. The partnerships would likely have other benefits as well. 

“Nursing homes should be encouraged to engage in partnerships with schools of nursing preparing registered nurses,” she said. “Not only could this increase career interest of nursing students in nursing home settings, the partnership can bring collaboration on designing and testing new care delivery models that support a stronger team model and supporting the accountability of the RN.”

LPNs and the mandate

The currently proposed form of the CMS staffing mandate does not include LPNs — an omission that has frustrated providers that often rely on LPNs to supplement a low number of RNs willing to work in the field. 

Despite this, Meuller argues that differentiating RNs and LPNs is still a worthwhile goal.

“I personally believe that CMS did not intend to minimize the role of LPNs in nursing homes,” she told McKnight’s, noting that less direct evidence exists of how LPN hours affect care outcomes.  “CMS did ask for comments on requiring a total nursing staff standard. A total staffing standard could be met with LPN hours (as well as additional RN and [CNA] hours).”

Changes outlined in the article would meaningfully improve quality and efficiency, Mueller said.

“[And] they can do it right now. No regulations or standards are needed,” she emphasized.