Homemade Care
Despite short staffing, strict regulations and relatively low pay, nursing home caregivers find rewards in their relationships with residents, colleagues

By Heather World
April 11, 2003

Quanadra Denise Hatcher, LPN, works in a nursing home, caring for the nation's most vulnerable citizens in an industry dominated by regulations, comparably low pay and high turnover.

Six days a week, Hatcher tends to as many as 36 patients, checking in on them and managing their medicine, as well as writing assignments for nursing assistants and conferring with doctors at the Beverly Health and Rehabilitation Center in Columbus, Ohio.

"It's a constant balancing act, and it's hard when you have so many patients and the patients are demanding," said Hatcher, who is working toward her RN license.

Care of the elderly is a sensitive field that is often the focus of publicity only when heart-wrenching tales of abuse surface. Now, the federal government has published online quality measures for homes, distinguishing one from another with disheartening statistics such as the number of residents with pressure sores, pain, restraints and infections, followed by a list of regulation violations. Without differentiating between levels of acuity, the Web site compares average nursing hours per patient to state and country averages.

While many homes welcome the scrutiny-many states already had more detailed versions of the federal Web site-the numbers listed do not always fairly represent what goes on inside the home, said Deborah Cloud, vice president of public affairs for the American Association of Homes and Services for the Aging.

"If a nursing home percentage looks out of line in one of those areas, there may be a valid reason why that's so," she said.

The information has placed added pressure on directors of nursing like Nyra England, RN, director of nursing at Beverly Health and Rehabilitation Center. England cited the bedsore statistic as an example.

"We have a low rate of people developing [wounds] here, but we have a high rate of accepting them from the hospital and healing them," she said. "You don't see that in the paper and on the Web."

The Centers for Medicare & Medicaid Services, the division of the Department of Health and Human Services that reimburses nursing homes for Medicare patients and publishes the Web site, found that homes should have a minimum of 4.1 hours of nursing per resident to avoid jeopardizing patients' health.

Scramble for staff

Yet many homes say they cannot keep their staffs full during a nursing shortage when hospitals are able to pay higher wages and sign-on bonuses, said Cindy Shemansky, M.Ed., RN, president-elect of the National Gerontological Nursing Association.

Shemansky blamed Medicare and Medicaid reimbursement in part. "For some residents, it's around $100 day; divided by 24 hours, that's about $4.16," she said. "If this is someone who needs 24-hour care, not necessarily [an] RN, you still can't hire with those wages."

England said she is always looking for more RNs. "Whether you're working in a hospital, nursing home or the private sector, nurses are hard to come by," she said.

On average, nonprofit nursing homes have better staffing ratios and look better in the federal ratings than their for-profit cousins, said Charlene Harrington, Ph.D., RN, FAAN, a professor of sociology and nursing at the University of California, San Francisco, who helped create her state's far more detailed nursing home comparison Web site.

"Nationwide, most of these proprietary homes cut on the staffing to make money," she said.

Kitty Ashton, RN, has worked in long-term care-both for-profit and non-for more than 20 years. She now works as the staff development coordinator at the nonprofit Cathedral Gerontology Center in Jacksonville, Fla. "With a nonprofit home, your profit goes back mostly into your facility," she said. "There are more positions available."

In Ashton's work experience, that difference has played out less in terms of quality of patient care and more in terms of how hard nurses must work. "Instead of doing one-and-a-half people's jobs, one person is doing a job," she said.

Even at Beverly, which has a relatively generous 4.23 nursing staff hours per resident per day, one absent nurse can create problems, Hatcher said. "Some days you can be very organized and the day can still go haywire," she said. "Basically, it comes down to not having enough staff."

Personal touch

Hatcher estimates she spends half her time looking in on her patients, assessing their condition and talking with them. Many suffer from depression, either because they don't like assisted living or they don't get many visitors.

"Good nurses will spend time talking to them and try to comfort them," she said.

Hatcher tries hard to give her patients a sense of stability in the middle of what can be a jarring experience. "When they have different nurses coming in and out, it totally disrupts them," she said of the patients. "They have to develop trust with you, and once they do, they know that when they go to that nurse and tell them something is wrong, the nurse is going to take care of it."

The other half of her time, Hatcher spends reviewing medicines, consulting with doctors and patients' families and filling out paperwork.

Kim Shephard, RN, has watched the proliferation of paperwork cut into the time a nurse would have to develop relationships with patients. "The state has all these guidelines and they are so picky," said Shephard, a two-year employee of Beverly with 19 years' experience.

Hospitals, she said by way of comparison, can be much more liberal, even in sensitive areas, such as the use of restraints and sedatives.

Added to the indignities of lower pay and closer scrutiny, many in the health care industry regard nursing home jobs as easy. "When I injured my back in the '80s, my aunt said, 'You should go to a nursing home, the work is easier,' " Shephard said. "She didn't know."

Nurses transferring from other settings often seem surprised at the caseload of a nursing home nurse, many in the field said. This in part accounts for the high RN turnover rate at long-term care facilities, estimated to be as high as 56 percent annually in a 2001 report issued by the American Health Care Association.

Yet nurses like Ashton find themselves drawn back into long-term care after working in new environments like psychiatric wards and prison systems. Ashton said she enjoys working with clients in a more holistic way-tending to their spiritual, psychological and social needs-and she also enjoys working closely with other medical professions, like psychiatrists.

"You're not bored," she said. "There's something different going on with somebody every day."

The job appeals to nurses who like the stability of a long-term care population coupled with the variety of issues that arise in elder care, she said.

The lure of the work is made stronger by the positive working environment for Hatcher, who has worked at two nursing homes run by Beverly Enterprises, which happens to be the largest nursing home company in the country.

"We help each other a lot, especially if something is going on with a patient or meds need to be out," she said. "That's why I won't leave."

Contact Heather World at H_world@yahoo.com