Working conditions in hospitals, nursing homes, and other healthcare are changing and have become increasingly difficult at an alarming rate. Meeting the demands of facility leadership and regulatory agencies is becoming increasingly difficult, while lean thinking is sweeping across the industry. These new conditions contribute to much of the stressors that healthcare workers endure. Burnout, compassion fatigue, overcrowding, and understaffing, to name a few, are at an all-time high. In particular, burnout is not a new concept in nursing; however, it had become mainstream over the last year due to the current COVID-19 pandemic. Before COVID-19, almost 50% of nurses considered leaving the profession altogether secondary to burnout. Can the nursing profession survive this onslaught? What needs to be done to reduce the stress on nurses?
Nurses on the Frontlines
Nurses and other healthcare personnel (HCP) are on the frontlines of this pandemic daily. They can attest to the unsafe working conditions. Before COVID-19, data gathered from nurses in New York, Illinois, and other US localities suggested that staffing ratios were increasingly dangerous. Nurses gave their facility low safety ratings and would not recommend their workplaces to friends or loved ones.
These were concerns nurses had long before the pandemic made its way into our nation and our homes. The pandemic has only increased these psychosocial stressors. Nurses have always dealt with daily repertoires of balancing constant change, high patient volumes with low staffing, increased error rates, low morale, and inconsistent clinical effectiveness. It was always something that came with the role, “that’s what you signed up for.”
For the first time in a while, HCP are speaking up. Now, they cannot leave what happens at work there. They can get infected and bring this virus into our homes to infect loved ones. When you carry the burden of potentially placing your family and others within your community at risk, it can become overwhelmingly heavy.
The Forgotten Stepchild
Long term care facilities (LTC) have always lurked in the shadows of more extensive hospital-based care facilities. Conditions in some of them are often suboptimal. Nurses are tasked with carrying resident loads far beyond what is deemed safe or acceptable in acute care settings. Often, these living conditions are a breeding ground for infection. The rate of pneumonia and urinary tract infections is significantly higher. The residents are complex total care patients who are at an increased risk due to their comorbidities. They are assigned to double occupancy conditions and congregate in share living areas. When more and more of these facilities began making the mainstream media due to the number of outbreaks of COVID-19, it became apparent there was a bigger problem at hand.
Nursing Home Reform Act
The Nursing Home Reform Act (NHRA) of 1987, yes, that is correct, 1987, states that residents of LTC are entitled to the following:
- Accommodation for physical, mental, and psychosocial needs
- Ability to communicate freely
- Treatment with dignity.
- Protection from mistreatment, abuse, and neglect
- Exercise self-determination
- Voice grievances without facing reprisal or discrimination
- Freedom from physical restraints.
- Participation in family and resident groups
- Participation in their care plan, including advance notice of changes in treatment, care, or facility status
Long-term care facilities strive diligently to ensure that residents receive quality care and meet daily essential residents’ rights. However, the truth is that with the large workloads, suboptimal staff training, and inadequate funding seen in nursing homes, these fundamental rights can be more of a delusion than reality. Do we continue to live in our illusion? How do we come to reality?
Unsafe Working Conditions
Depending on the work shift, it is entirely acceptable for a licensed practical nurse to care for a patient load of up to 40 patients at a time in a congregate living facility depending on the state. If these same conditions were present in a hospital setting, there would be uproar as expected. Some may argue acuity is lower; however, most residents of long-term care facilities have complex comorbidities and require dependent care.
Nurses working in these facilities are tasked with:
- Wound care and dressing changes
- Administration of IV medications
- Resident Activities of daily living
- Tracheostomy care
- Complex medication administration
- Resident documentation
- Checking vital signs
- Monitoring blood sugars
- Transcribe physician’s orders
- Infection Control
The list goes on, but the point remains the same. These conditions, coupled with suboptimal staff training, make it challenging and stressful for the nurse; these conditions also breed opportunities for significant medication errors and infections alike.
Suboptimal Staff Training
Staff in long term care facilities are often undertrained. In recent years, many long-term care corporates and independent facilities have tried to bridge the gaps in staff education, making available asynchronous self-paced learning videos to staff to meet the minimum regulatory obligations. These efforts though laudable, and convenient, are not without setbacks. The heavy staff workload makes it almost impossible for staff to find time out of their busy schedules to log on and complete assigned modules. Also, the inadequate number of computers set for staff use makes meeting education module deadlines difficult. These conditions inadvertently add to staff stress and frustrations and ultimately lead to burnout and high staff turnover in long-term care settings.
It should also be noted that with the introduction of these online training programs, long-term care facilities over time have minimized the role of the nurse educator or staff development coordinator. The staff development role is often merged with the infection preventionist or the assistant director of nursing roles. Consequently, the monitoring of staff compliance in completing assigned online course modules and developing comprehensive staff competency training continues to be a challenge.
The Covid-19 pandemic has brought to bear poor staff knowledge of basic principles of infection control practices in many instances, and it has been costly and deadly. We should be calling for staff training reforms in long term care settings. Also, improving the working conditions for nurses and nurse assistants working in such environments must be a priority.
Where Do We Go From Here?
COVID-19 is a wake-up call for the long-term care industry (LTC). There will be more and stricter regulatory standards proposed to protect both residents and staff alike. The question, however, is, does the long-term care industry need more regulatory oversight? Before the pandemic, federal and state agencies in the US burdened long-term care facilities with over 200 regulations. As a Director of Nursing in a long-term care facility, I can attest that keeping up with these regulations does add to the stress and burnout of all staff members. At the minimum, it takes away time from staff education, direct resident care, and implementation of comprehensive infection control programs.
Admittedly, this burden is not shared only by long term care facilities. However, given that regulations are inevitable, the long-term care industry needs adequate funding to fully implement current and upcoming reforms, such as comprehensive staff development and training programs.
Additionally, nursing education should develop a curriculum tailored to the long-term care nurse to bridge the existing gap between education and practice. It is time for nurse leadership to look at how current regulatory oversight impacts caregiving in these settings and advocate for change.
While we wait for reforms, long-term care facilities can start taking care of their staff’s mental health by providing onsite counseling and therapy sessions and developing activities and resources for staff geared towards stress reduction. For example, what about providing a workout gym facility for staff, yoga program, walking group, reading club, etc.?