Authors

  1. SCHNELLE, JOHN F. PHD

Article Content

The articles in this journal issue capture the viewpoints of consumer advocates, providers, and the research community about issues concerning nursing home (NH) staffing. There is consensus that many quality problems are related to work-force issues, even though the stakeholders emphasized different aspects of the workforce that are problematic.

 

The articles by Harrington and also Wells and Hughes primarily focus on the issue of nurse staffing numbers. These authors summarized research which indicates that inadequate staffing levels are related to quality problems. The authors suggest solutions to this problem including the development of minimum staffing ratio policies, better regulatory enforcement of existing staffing standards, and new reimbursement systems to support increased staffing. Stone et al also acknowledge that the number of direct care workers may be inadequate. However, this article focuses more on issues related to how the workforce is trained, managed, and paid. The Stone et al article makes a persuasive case that innovative training, management, and incentive programs must be developed if long-term care workforce problems are to be resolved. Two examples of such projects are provided in the articles by Cohen and Forrest and Hollinger-Smith and Ortigara. Stone et al also make the important argument that discussions about the long-term care workforce and quality should more often consider the relationship between the resident and the caregiver. There are indications that caregivers feel that they do not have adequate time to communicate with residents in a more personal manner.

 

The articles by Schnelle and Simmons as well as McGilton provide a more specific discussion of some of the points raised in the previous articles. The Schnelle and Simmons article provides an example of a technology that can be used to match workforce resources to residents' needs in the area of feeding assistance. The argument is made that this technology should be used to assure that the direct care workforce is provided realistic job assignments, which is a necessary first step to developing more effective training and management programs as discussed by Stone. It is difficult to conceive how effective staff management can occur if the starting point is an unrealistic job assignment. The article by McGilton also further develops points made in the Stone et al article by describing a measurement technology that can be used to monitor the quality of the relationship between residents and caregivers. Such a measurement technology is clearly a prerequisite to better training and management in this important care area.

 

The points made about staffing in this journal issue are particularly important when considering residents with Alzheimer's disease. This population is unique in that they are often physically capable of many activities required for independence and enhanced quality of life, but they do not initiate these activities without extensive prompting and supervision. Motivating these residents to complete activities and not providing excessive care that creates dependence are major care challenges, which requires excellent caregiver communication skills. Moreover, it is difficult for caregivers to communicate with residents in an effective manner if they are driven by time-efficiency concerns. In short, you cannot hurry an Alzheimer's resident through a meal because of inadequate staffing and at the same time provide care that maximizes independence or life quality.

 

Unfortunately, we know very little about how labor intense care, which emphasizes excellent communication, may be. The recent work by Simmons et al in the area of feeding assistance provides some information about this issue. In the Simmons'work, residents who are physically capable of eating independently but who do not do so can be motivated to eat well during either meals or snacks through a graduated-prompting protocol. This protocol relies on excellent communication between a resident and the caregiver, but it is labor intensive to implement. It is estimated that 1 aide can effectively communicate and provide assistance to approximately 3 residents, even under assumptions of high work efficiency.

 

It seems obvious that the type of work illustrated with feeding assistance should be extended to other areas to answer questions about how many caregivers are necessary to provide high-quality interpersonal and technical care to residents with dementia. Fortunately, this information could be gathered with an organized research effort in a relatively short period of time. It is surprising that such research has not already been conducted given the high level of concern about long-term care quality and the growing population of residents with dementing diseases.