1. Kovner, Christine Tassone PhD, RN, FAAN
  2. Harrington, Charlene PhD, RN, FAAN

Article Content

Assisted living facilities (ALFs), one of the fastest growing housing options for older adults, represent a potentially new employment option for RNs. About 70% of ALFs employ an RN or LPN but the increasing number of frail older adults moving to ALFs suggests there will be a need for additional nursing care.


Slightly fewer than 1 million people age 65 or older live in an estimated 33,000 ALFs, in private or shared units. Known by different names (such as board and care homes), all ALFs provide congregate meals, laundry and housekeeping services, and some social activities; virtually all provide health monitoring and assistance with activities of daily living (ADLs).


The average resident is white and female, widowed, and in her early 80s. Approximately 60% of residents need assistance with one to three ADLs; 75% need assistance with medications. Current estimates suggest that 50% of residents in ALFs have Alzheimer disease or dementia, and the number of residents with dementia is expected to grow. Approximately 25% of ALFs have a dedicated Alzheimer or dementia unit. ALF residents take more medications, including psychotropic agents, than nursing home residents. Annually, 11% of residents are transferred to a hospital, 26% die in the facility, and 24% to 40% are discharged to a long-term care facility.


The number, type, and training of ALF staff members vary with state regulations, number of residents, and residents' personal and health-related service requirements. Staff can be directly employed, contracted, or obtained by coordination with an outside agency, such as a home care agency. My review of state regulations found that 22 states permit unlicensed staff to administer medications. Some states permit residents to remain in ALFs if they are temporarily, acutely ill; other states permit and indeed encourage admission to ALFs of residents at a nursing home level of care. Skilled nursing is available in 60% of ALFs, generally provided by a contract with a home health care agency. In all states, a licensed hospice agency may provide end-of-life care in ALFs.-Ethel L. Mitty, EdD, RN


Sources: Kraditor K, et al. Assisted Living Sourcebook. Facts and Trends. Washington (DC): National Center for Assisted Living; 2001.


Research Brief

Personal Care and Health-Related Services in Assisted Living

In 2000 Hawes and colleagues reported on a nationally representative sample survey of staff and residents at 300 ALFs. The authors classified ALFs as either low- or high-service and minimal- or high-privacy facilities. A low-service ALF provided housekeeping and personal-assistance services, 24-hour oversight, and at least two meals a day. High service is the same as low service but with the addition of one full-time RN. Minimal-privacy ALFs featured apartments shared by at least three residents, and in high-privacy ALFs 80% to 100% of the occupants lived alone. Forty percent of residents of high-privacy and high-service ALFs felt they were in fair or poor health, and their greatest concerns were staff shortages and high turnover. Overall, hospitalization rates for ALF residents, including those in high- and minimal-privacy facilities, were much higher than in the general population of older adults. Annually, one-third of residents were discharged to a hospital or nursing home.


Staff experience. Approximately 50% of ALFs' staff who were not RNs were unable to identify side effects of antipsychotic drugs. At least 60% did know how to properly manage difficult behavior such as not cooperating in daily care activities like bathing, but only 8% were knowledgeable about the normal aging process. For example, 88% of staff thought that confusion was just a consequence of aging, and 80% thought that urinary incontinence was a normal part of aging.


Staff workload. On average, there was one personal care aide to assist 14 residents, but the workload wasn't regarded as heavy even though tasks included laundry, meal services, and housekeeping. Despite poor pay and scant opportunity for advancement, most staff members were satisfied with working conditions.-Ethel L. Mitty, EdD, RN


Source: Hawes C, et al. High service or high privacy assisted living facilities, their residents, and staff: results from a national survey. Rockville, MD: U.S. Department of Health and Human Services.; 2000.




[black down pointing small triangle] Close to 1 million older adults (65 and older) lived in one of approximately 33,000 assisted-living facilities in 2001.


[black down pointing small triangle] In 2000, 40% of assistedliving facilities employed RNs who were either directly employed by the facility or contracted.


[black down pointing small triangle] Assisted-living-facility residents took an average of six medications per day in 2000.


[black down pointing small triangle] In 2000, 24% of assistedliving facility residents took nine or more medications per day.


Sources: Kraditor K, et al. Assisted Living Sourcebook. Facts and Trends. Washington (DC): National Center for Assisted Living; 2001Armstrong P, et al. Medication usage patterns in assisted living facilities. The consultant pharmacist 2001; 16 ( 1 ): 39-43.


Nurse Staffing in Assisted Living Facilities

As the role of ALFs in long-term care evolves, nurse staffing issues are undergoing a fair amount of scrutiny at both the federal and state levels. A recent government report noted that inadequate staffing in ALFs was a major quality-of-care issue nationwide.


Approximately 70% of the larger ALFs built since 1987 report having an RN or LPN on duty or on call for some portion of the day or week. Most states' regulations require ALFs to have "sufficient staff" to meet residents' "scheduled and unscheduled" needs, 24 hours a day. Fifteen states have minimum-staffing ratios. Some states require a licensed nurse but do not specify RN or LPN. Other states require that an RN be available 24 hours a day but not necessarily on site, or only when medications are administered. At least half of the nursing care services and almost four-fifths of the skilled nursing care is provided by contract nurses, either employed privately by the resident or on contract with the ALF from a licensed home-care agency.


Registered nurses' responsibilities, which vary state by state, can include performing assessments on admission and periodically, medication review, resident assessment regarding a reported change in physical condition and mental status, weight or cognitive changes, care plan development, and staff monitoring. They also perform wound care, glucose meter and vital sign readings, oxygen administration, injections, and ostomy care. In some states, these activities can be delegated to unlicensed staff. Few states require the personal care aide to be certified. Only 11 states require that nursing staff receive education in age-related changes, psychosocial needs, and death and dying. Despite the growing number of ALF residents with Alzheimer disease or dementia, only 15 states require education specific to those conditions.


As is the case with other health care facilities, ALFs have difficulty recruiting and retaining nurses. A 2001 unpublished survey by the American Assisted Living Nurses Association showed that approximately 50% of RNs working in ALFs have worked in nursing homes. Turnover, at 45%, is higher among RNs, followed by nurse assistants and LPNs, at approximately 35%. Recruiting issues for RNs include salaries and benefits, which aren't typically competitive with local health service wages, and the work environment and management style, which currently don't encourage RNs to remain invested in assisted living nursing as a career.-Mathy Mezey, EdD, RN, FAAN


Sources: Office USGA. Assisted living: quality-of-care and consumer protection issues in four states. Washington (DC): Government Printing Office; 1999Kraditor K, et al. Assisted Living Sourcebook. Facts and Trends. Washington (DC): National Center for Assisted Living; 2001Stearns S, Morgan L. Economics and financing. In: Zimmerman S, et al., editors. Needs, practices and policies in residential care for the elderly. Baltimore: Johns Hopkins University Press; 2001. vol. 2001. p. 271-91Hodlewski R. Staffing problems and strategies in assisted living. In: Zimmerman S, et al., editors. Needs, practices and policies in residential care for the elderly. Baltimore: Johns Hopkins University Press; 2001. vol. 2001. p. 78-91.