Annals of Long Term Care

“Why did you want to be a nurse?” is a question that commonly appears on nursing school applications and is often asked during interviews with nursing candidates. In a recent conversation with some of my fellow seasoned nurses, we recalled this essential question and chuckled as we shared our similar responses: “I want to help others,” “I enjoy working with people,” “I see helping people improve their health as special work that I feel called to do.” Although our view of nursing may have been simplistic and naïve, we launched our careers wanting to serve people—not just perform tasks—but to engage with other human beings. We proceeded to learn how to care for the whole person, including their physical, mental, psychosocial, and spiritual needs. Although we performed many procedures to prevent and treat various health conditions, they were components of our multifaceted approach to caring for our patients, but not our sole contribution. The nursing landscape has changed, however. When examining today’s nursing activities in many typical long-term care (LTC) settings, nursing functions are often fragmented, contributing to less emphasis being placed on the people we have been enlisted to serve.

Tasks and Silos

Fragmentation can be found at all points of care in nursing homes. Newly admitted residents are assessed by a coordinator of the Minimum Data Set (MDS), and care plans are often developed without the participation of the frontline caregivers, who spend the most time with residents and come to know them best. When pressure ulcers occur, they are evaluated and treated by a wound care nurse, whereas a resident’s medications are administered by a nurse who may have little to no involvement with the resident beyond this activity. Other services, including ambulation, cognitive stimulation, exercises, feeding, and lifting, may be performed by a host of different staff members, whose only contact with the resident occurs when the activity they are responsible for needs to be performed.

The focus on meeting regulations further fragments care. Regulatory requirements regarding the provision of nursing care in LTC settings are essential, as standards must be met to keep facilities licensed, and more importantly, to provide the foundation for safe care; however, regulations often only ensure that the very basics of care are met. They do not guide holistic or total-person care. Although residents need much more from nursing than is required by regulations, in many situations regulations drive nursing functions.

At the end of the day, tasks must be completed to ensure regulatory compliance is met, but has anyone ensured that residents’ complete needs are being met? Has any single nurse spent a sufficient amount of time with any  resident to identify a subtle change in his or her function, recognize a distressed spiritual state, discover his or her feelings about a recent family visit, or offer comforting words?

The fragmented, task-oriented approach to care is the result of many factors. Historically, nursing home care evolved in a disorganized manner, rather than by following a defined model. There was no leadership that described nursing standards and practice for patients with chronic care needs requiring institutional support. Owners and operators of nursing homes did not develop a model for their settings that considered the holistic needs of the population served and the best strategies to meet them; instead, they looked for the most cost-effective means of satisfying regulations that addressed only basic requirements. Third-party reimbursement barely covered the cost of meeting those basic regulatory requirements, thereby limiting the incentive and ability of owners and operators to develop care models that provide comprehensive, coordinated, and individualized care to residents.

Nursing is hardly blame-free in the development of this problematic approach to care. Nurses, ironically, lacked leadership presence in the development of nursing home care models, despite the use of the profession’s name in the label for this form of care. The voice of nursing was noticeably absent when Medicare and Medicaid were being developed in the 1960s, and when lobbyists for nursing home owners and the American Medical Association were offering Congress direction as to the standards that would enable nursing homes to participate in these reimbursement programs. Even in the subsequent decades, there was no unified voice of protest from nursing professionals when a significant number of nursing homes provided substandard care and were staffed with an inadequate quantity and quality of nurses. Nursing schools provided little, if any, instruction related to the unique aspects of geriatric care, including of chronic diseases and LTC in general, a pertinent consideration since most LTC nurses represent a generation that attended nursing school several decades ago. Efforts to transform the culture of nursing homes to promote higher quality care that is centered on and directed by residents have been led by consumers and disciplines outside of nursing.