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“Get out of here! Take that thing off your face! I was a nurse, I know what that thing is. I’m not going to the operating room! Where is my daughter?” Mary Knapp, RN, MSN/GNP, NHA, FAAN, director of health services at Foulkeways at Gwynedd in Pennsylvania, took to the stage at PALTC22’s opening general session with a frank impression of what nurses and other staff have heard from residents during the pandemic. For months, she observed, they’ve had to deal with issues and challenges they couldn’t have imagined two years ago. All this has taken its toll, and rebuilding the nursing workforce will include supporting the physical and emotional health of these individuals.
Panelists at the opening general session of the PALTC22 conference, from left to right: Emily Nicoli, Dr. David Grabowski, and Mary Knapp, with moderator Dr. Diane Sanders-Cepeda.
Nursing varies from setting to setting to some degree, Ms. Knapp observed. For example, she said, “in personal care and assisted living, you really have to hunt out who is a licensed, trained nurse. Nursing homes are different. The nurse staffing requirements in nursing facilities are governed by states, and each has different requirements.” However, she noted that patients and families don’t necessarily know this, which can lead to unrealistic expectations. “All they know is that there are nurses when they enter the facility.” They don’t know that the facility may be short-staffed and that a nurse or certified nursing assistant (CNA) is caring for twice as many residents because their colleagues are out sick or taking on tasks and responsibilities that take time from direct patient care.
Often, Ms. Knapp said, “licensed nurses are stuck on the med cart administering medications to 30 residents.” This presents an important opportunity for other team members to help ease the burden on the nursing staff. For instance, physicians and advanced practice providers may reconsider orders for some vitamins; or practitioners and pharmacists can work together to reduce dosages, eliminate duplicate or unnecessary medication, or make other changes that can reduce medication administration time.
Another opportunity to ease unnecessary burdens on nursing staff and increase their ability to focus on direct patient care involves a policy change. “Stop nighttime and weekend admissions to facilities,” Ms. Knapp said. “Hospitals could do better planning if facilities said ‘no’ to these admissions.” Facilities would have to agree to this on a widespread basis. If only a few did it, she suggested, this would just put a greater burden on the staff at the facilities that continued to accept residents during evenings and weekends.
Whatever steps facilities take to ease their nursing shortages and better engage staff, Ms. Knapp suggested, “there needs to be a philosophy of respect.” If you provide a culture were nurses’ time, roles, needs, and concerns are addressed, she said, “they’re going to love you.”
Caring for Caregivers
David Grabowski, PhD, professor of health care policy at the Harvard Medical School in Boston, MA, started his presentation by praising the CNAs who have cared for residents throughout the pandemic. “Thanks to all the CNAs. They are the backbone of health care and long-term care. This can’t be said enough.” Yet, he noted, “unfortunately, we haven’t cared very well for caregivers in the past two years.”
In an article he wrote for Politico, Dr. Grabowski outlined several ideas to improve care and staffing in nursing homes (Mar. 11, 2021, https://politi.co/3JKPp5Y). These include increased financial transparency, minimum staffing standards, increased pay and benefits, higher reimbursement rates, more career advancement, and an improved work environment. “You may have additions to this list, but these are my six places to start,” he said.
“Finally, nursing homes are getting some attention,” he said. Most recently, President Biden addressed this care sector in his State of the Union address. Dr. Grabowski referred to some of the major reforms the administration is focusing on: a minimum staffing standard, increased quality accountability, and better quality and ownership transparency. “These are three great measures in isolation, but they’re not going to do it by themselves,” he said. “We need more, but this is a start.”
Getting Nursing at the Table
“We’re talking about how to make improvements in nursing staffing, but there aren’t many nurses in this room. We need to make sure we engage them in the conversation,” said Emily Nicoli, MSN, CRNP, AGNP-C, ACHPN, chief nursing officer at United Healthcare Retiree Solutions in Boynton Beach, FL. She stressed the urgency: 30% of nurses are leaving the profession within their first two years of work.
Ms. Nicoli told a real-life story exemplifying why nurses leave. She explained how the Lyft driver taking her to the airport for the conference had previously been a long-term care nurse. “He left the setting because it had become too stressful and wasn’t worth the time and energy anymore. It was heartbreaking for me.” She further noted that this isn’t an isolated incident. “About 30% to 40% of the Lyft drivers I’ve encountered were health care providers, specifically nurses or aides,” she said. We are “churning and burning our nursing staff and CNAs,” she observed.
Nurses are leaving long-term care for one or more of four basic reasons, Ms. Nicoli suggested. These are workload, environment, culture, and physical/emotional strain. Part of the problem, she said, is that “the field is stigmatized.” At the same time, culture is an issue. “We live in a culture where we don’t appreciate older people, and this needs to change.”
It’s important to step back and try to understand the emotional and mental toll that past 18 months have taken on the nursing staff in post-acute and long-term care, Ms. Nicoli said. “Imagine if you are a nurse or CNA and you spend all day every day with residents. They are like family. Now imagine how hard it is to lose these patients,” which was an all too frequent occurrence during the pandemic.
What’s the answer? It’s not easy, Ms. Nicoli said, but there are some important steps to take. For starters, she offered, “remember that nurses are just as important as other members of the interdisciplinary team. We all need to understand what our roles are and that some of our roles overlap.” She suggested a few other action items for medical directors, physicians, nurse practitioners, physician assistants, and other leaders and colleagues:
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Show appreciation.
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Ask questions of nursing staff.
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Get to know the nurses and CNAs.
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Advocate for the nursing team.
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When writing orders, consider the impact on nursing time.
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Consider the need for tasks such as daily weights.
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Be courteous on calls.
Ultimately, Ms. Nicoli said, “it all boils down to being kind. Being kind and having a good culture in the facility comes down from the top in the facility, and it is so important.” This not only has a positive impact on staff but also on residents. She explained, “Happy staff provides better care.”
Senior contributing writer Joanne Kaldy is a freelance writer in New Orleans, LA, and a communications consultant for the Society and other organizations.
In this episode Karl Steinberg and Elizabeth Galik reflect on the PALTC22 conference, including how to support nurses to ease the workforce crisis and formulating and communicating prognoses. We also discuss the power of social relationships in long-term care and a legal issues column on medication errors and homicide.
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