How to optimise the registered nurse contribution in care homes

This article aims to offer ideas that may be useful to care homes when considering priorities for registered nurse (RN) work. Drawing on the findings of research into the work of RNs and care assistants in UK care homes (Heath 2006), it discusses the distinct contribution of RNs, the delegation of nursing interventions and the need for a 24-hour RN presence. International debates on the distinct contribution of RNs in residential settings for older people are also acknowledged.     

To both be like a captain and fellow worker of the caring team: the meaning of Nurse Assistants' expectations of Registered Nurses in Swedish residential care homes

Aim.  To describe the expectations of and to illuminate the meaning of the Nurse Assistants' (NA) expectations of Registered Nurses (RN) who are responsible for the care of older people living in residential care homes in Sweden.
Background.  Older people in Sweden who are provided with residential care are extremely frail and incapable of independent living. Therefore, when providing care, RN and NA encounter older people who require a great deal of care. An important precondition for the provision of satisfactory care is to have adequate collaboration between NAs and RNs and their expectations of each other. In this paper, the focus is on the NAs expectations of the RNs.
Method.  The study is based on a qualitative approach and a phenomenological-hermeneutical method. Ten NAs were interviewed and asked to narrate as freely as possible, about their expectations of RNs. The narratives were audio taped and transcribed verbatim. The analytical process includes the following steps; naïve reading, structural analysis, comprehensive understanding and reflection.
Results.  The RNs were expected to take responsibility for being fellow human beings and experts in providing care as well as always available to participate in caring. The RNs were expected to make stand-alone decisions and create a sense of safety for both older people and the NAs and have the courage to work alone and create a safe environment for both the older people and the NAs. The meaning of these expectations was that the RNs are like a captain in providing care, but at the same time, fellow workers.
Conclusion.  When the RNs do not meet the NAs expectations, there is a risk of conflict and therefore also a risk that an unsafe environment being created when caring for older people.     

Effects of registered nurse staffing on quality of care and resident outcomes in nursing homes

Few studies focus on Registered Nurse (RN) staffing and resident health outcomes in Korean nursing homes. This study aimed to investigate the effects of RN staffing on quality of care and resident outcomes in South Korean nursing homes. The study was a secondary data analysis of 5679 participants from the National Health Insurance Service. A mixed-effect linear model and multinomial logistic regression model assessed resident outcomes and quality of care, respectively. The number of RNs significantly affected patient mortality. The overall evaluation rating for quality of care in nursing homes increased as the number of RNs increased. Level of RN staffing in nursing homes influenced health management and quality of care for residents. A variety of efforts are needed to strengthen the workforce of RNs in nursing homes, including enacting a law for safe RN staffing and converting the evaluation of nursing home quality into health outcomes.     

Older women nurses: health, ageing concerns and self-care strategies

Title. Older women nurses: health, ageing concerns and self‐care strategies Aim. This paper is a report of a study of the health and ageing concerns and self‐care strategies of older female Registered Nurses currently working in direct care‐giving roles in acute public hospitals and community facilities. Background. Nursing is a rapidly ageing, and female‐dominated workforce. However, despite the ageing of the nursing workforce, little is known about the needs and health concerns of older nurses. Method. A feminist perspective was used and 12 female Registered Nurses aged 40–60 years, employed in various acute hospital and community health settings in Australia took part in qualitative interviews in late 2004. Narratives were audio taped, transcribed and analysed thematically. Findings. Two major themes were identified. The first theme –Aches and pains of ageing– had four subthemes: Neglecting self: ‘You don't think of yourself first’; Physical changes: ‘The body is wearing out’; Living with pain: ‘You just work around it’; and Tiredness: ‘I’m just tired all the time’. The second theme –Evolving lifestyles: works in progress – had three subthemes: The power of exercise: ‘I feel great…and I’m enjoying life’; Healthy eating: ‘Low fat, lots of fruit and veg, little processed food’; and Adapting to ageing: ‘I think it’s quite a good time of life’. Conclusion. Further research is needed to explore the need for protective work practices and promoting healthy lifestyle practices for ageing nurses. Managers need to recognize the changing health needs of older clinical nurses and offer, for example, flexible rostering and tailored exercise programmes to promote their health.     

Coming and staying: a qualitative exploration of Registered Nurses' experiences working in nursing homes

Aim. This paper reports on a qualitative study that explored the reasons why Registered Nurses (RNs) chose to work in nursing homes in Southern Ontario, Canada and what factors attracted them to remain.
Background.  There is a paucity of information about factors associated with the recruitment and retention of RNs within long-term care (LTC) in Canada. As the population of older people is growing in Canada and elsewhere, it is essential that we better understand what attracts RNs to work and remain in this setting.
Design and method. A case study approach was used in this study of nine RNs working in three nursing homes. Data were collected through in-depth interviews.
Findings. Six sub-themes were identified: 'Job of Choice', 'Job of Convenience', 'Caring for the Residents', 'A Supportive Environment', 'Heavy Workload' and 'Supervisory Role of the RN'.
Conclusion. Nurses chose to work in the nursing home because it was a 'Job of Convenience'. However, characteristics of the organizational environment played a major role in their remaining. Also, the caring relationship with residents played a role in the nurses remaining in this setting.
Relevance to clinical practice. Strategies are provided that nurse managers may consider when planning recruitment and retention activities for LTC settings.     

Registered Nurses working together with family members of older people

Aim. The aim of the study was to reach a more profound understanding, through looking at nurses’ working situation, of those factors that influence how nurses are able to work together with family members of older people living in nursing homes or similar facilities. Background. Working with the care of older people as a Registered Nurse provides a varied job with many challenges. Nurses have to co‐operate with family members of those in community health care. Co‐operation is important and necessary for all involved. Design. Nurses working in elder care in a geographically defined area received a questionnaire with three open‐ended questions, on the difficulties and/or problems involved with working together with family members, and the positive or negative aspects of this co‐operation. Methods. Analysis was carried out using the latent content analysis method. Results. Three themes, problems within the system, interaction with families and caring in nursing work, are presented with categories and their subcategories. The nurses wanted their superior to be a nurse so that their working situation would be better understood. Appreciation from their superior and family members was also a very important part of their work as nurses in community health care. The frequent changes and the lack of time in the work of elder care often put nurses under considerable psychological pressure. For the most part family members are a resource for the elder, but sometimes they will avoid contact, which will make co‐operating difficult. Conclusion. Registered Nurses and family members are dependent on each other in their care of the elder. Relevance to clinical practice. More attention should be paid to the working situation of Registered Nurses in community health care, and their ability to work together with family members of older people.     

Home-based care for people with disabilities: Role of registered nurses within the District health system in Thailand

BackgroundIn Thailand, the number of people with physical disabilities (PwD) has been increasing. Following sweeping health care reforms in 2002, efforts were made to improve accessibility to health care by greatly increasing the number of Registered Nurses (RNs) working in local community health centres. Little is known, however, about the role of RNs in improving accessibility to home-based care and the outcomes of care for PwD in Thailand.AimTo explore the role of RNs in providing high quality home-based services for PwD who have severe limitations in movement.MethodsA case study design was used to explore and describe the role of RNs in home-based care for PwD in one rural and one urban area in lower north Thailand. There were 73 participants, including PwD and their family members, community health volunteers, primary care providers, local government officers and members of the District Health management team. Data were collected from in-depth interviews and focus groups, which were analysed using thematic analysis.ResultsThe roles of RNs in home-based care for PwD were found in four domains, as case manager, rehabilitation care provider, manager of the community health volunteers and broader care coordinator.ConclusionThe full scope of the RN role in the provision of home-based care for PwD, in the district health system of Thailand, not only involves direct nursing care. The role also encompasses planning and co-ordination of the broad range of professional and non-professional services to meet the needs of PwDs in rural and urban settings.     

Observing how RNs use clinical time in a nursing home: a pilot study

Registered nurses (RNs) working in nursing homes (NHs) are a scarce professional resource. Their responsibilities include direct (e.g., assessment, physical care, and medication administration) and indirect care (e.g., documentation, supervision, and other activities performed away from the resident to manage their care environment). The purpose of the study was to describe the direct and indirect care distribution of RNs working day shift in an NH. All RN care was observed, although RN care associated with pressure ulcer prevention as a clinical outcome was highlighted. Work sampling was conducted using a personal data assistant-based RN Observation Measure. RNs spent 59% of their time on indirect care. Little direct care could be linked with specific clinical categories relevant to pressure ulcer prevention. RNs are challenged to use RN clinical time more strategically.     

Experiences with advance care planning: nurses' perspective

jeong s.y.‐s., higgins i. & mcmillan m. (2011 ) Experiences with advance care planning: nurses’ perspective. International Journal of Older People Nursing  6 , 165–175 doi: 10.1111/j.1748‐3743.2009.00200.x Aims and objectives. The aim of this paper is to report the findings of a case study that explored the phenomenon of advanced care planning and advance care directives in residential care settings in Australia. In particular, this paper focuses on the experiences of Registered Nurses with advanced care planning and advance care directives. Background. Nurses need to know how to engage with residents and families when they invest time and effort on advanced care planning and documentation of advance care directives. Methods. A case‐study design involving participant observation, field note recording, semi structured interviews and document analysis was used. Data were collected over 7 months. Data analysis involved thematic content analysis. Findings. The factors that enhanced and inhibited the experiences of the Registered Nurses with advanced care planning were identified. The enhancing factors include; ‘it is their essence of who they are’, and ‘back‐up from family members and other nursing staff’. The inhibiting factors are ‘lack of time’, ‘a culture of do everything and don’t go there’, and ‘lack of family involvement’. Conclusion. The findings of the current study provided nurses with evidence of the positive nature of experiences of older people, family members, and nurses themselves with advanced care planning in an attempt to better implement and practise advanced care planning.     

The professional development needs of registered nurses in residential aged care

This paper reports on research which used a multiple-case study approach to investigate the responses of aged care nurses to changes in Australian health care policy following the introduction of the Aged Care Act 1997. Significant fiscal, social and environmental issues for Residential Aged Care (RAC) are the: need to respond to policy changes emphasizing efficiency in RAC facilities, nature of the needs of residents with increasing acuity, impact of decreasing numbers of Registered Nurses (RNs) working in the RAC environment, changing composition of the care team and RAC RN functions. The study explored the phenomenon of the contemporary practice of (RNs) within six RAC settings, focusing on changes in the practice of RNs. As a result of the research a number of issues pertinent to staff and role development of RNs were identified.     

Perceptions of registered nurses working with assistive personnel in the United Kingdom and the United States

This study examines registered nurse perceptions of their role in acute care hospitals that use nursing care assistants (NCA) and unlicensed assistive personnel (UAP). Also studied was registered nurse (RN) satisfaction with nursing care assistants and unlicensed assistive personnel in the United Kingdom (UK) and the United States of America (USA). The purpose of this study is to assist RNs and managers in the re-design of health-care delivery systems by investigating: 1. The differences and similarities of registered nurses in the UK and the USA in the perceptions of changes in the RN role when working with nursing care assistants or unlicensed assistive personnel. 2. The differences between and similarities of registered nurses in the UK and the USA in perceptions of NCA and UAP abilities to perform delegated duties, to communicate pertinent clinical information and to provide more time for professional nursing activities. Registered nurse perceptions in the UK were compared with the findings of a previous study of RN role changes and satisfaction in the USA. Registered nurses in the UK did not perceive a profound change in their role when working with UAP and were more satisfied with their use than were RNs in the USA.     

To feel betrayed and to feel that you are betraying the older residents: caregivers' experiences at a newly opened nursing home

Background. In Sweden and internationally, little research has focused on the working situation of Enrolled Nurses and Nurses’ Aides who form the majority of workers in geriatric care today. With this in mind, it is important to focus on how these occupational groups experience their working situation with older residents in municipal care. Aims and objectives. The aim of the study was to investigate the deeper meaning of work satisfaction and work dissatisfaction at a newly opened nursing home for older residents. The study focused on the narratives supplied by the caregivers at the nursing home. The participants included: one Registered Nurse, sixteen Enrolled Nurses, and three Nurses’ Aides. All were directly involved in patient care. Design. The present study is part of a larger longitudinal study within the municipal geriatric care system in Sweden, with a quasi‐experimental design. Method. The interviews were analysed with a phenomenological‐hermeneutic method inspired by the philosophy of Ricoeur. Result. The caregivers experiences of work satisfaction and work dissatisfaction was expressed in four themes: (i) ‘Experience of betrayal’ describes how the staff felt let down in several ways; (ii) ‘Experience of failing others’ describes how the staff felt that they did not pay enough attention to older people, in several different ways; (iii) ‘Experience of insufficiency’ describes how the staff encountered overwhelming demands from several directions; (iv) ‘Experience of work satisfaction’ describes how the staff felt that they were given support in various ways. Each theme emerged from several subthemes that originated from the caregivers’ narratives. Conclusions. The study shows that the caregivers’ experience of work dissatisfaction overshadows their experience of work satisfaction. It also suggests that their feelings of failing the older residents are connected to their own experiences of feeling betrayed. Relevance to clinical practice. The findings can be used when other nursing homes in municipal care are opened, as a means of preventing work dissatisfaction and increasing work satisfaction among future employees.     

Gerontological nursing roles within the Southeastern Regional Geriatric Program

This paper looks at the varied roles of Registered Nurses (RNs) within the Southeastern Regional Geriatric Program (SERGP) and how these nursing roles influence client care across the continuum of services. More specifically, this paper describes the clinical services of the SERGP, the roles of RNs within these services, and the principles and dimensions of geriatric nursing assessment, treatment, and rehabilitation. The aim of this article is to promote recognition of the complex and stimulating work of RNs in gerontology. Eliopoulos (1997) states the following that reflects this excitement and complexity: Gerontological nurses help older individuals to achieve a sense of wholeness by guiding them in understanding and finding meaning and purpose in life, facilitating harmony of the mind, body, and spirit, mobilizing their internal and external resources, and promoting self-care behaviours.     

Older people living in nursing homes or other community care facilities: Registered Nurses' views of their working situation and co-operation with family members

Background. Little attention has been paid to Registered Nurses’ working conditions and how they experience their working situation in community health care. The nurses’ vocational background is of interest, as well as their apprehension about communicating and co‐operating with the older persons’ family members. Aims and objectives. The aim of the study was to describe Registered Nurses’ views of their working situation in community health care and of co‐operation with family members of older people living in nursing homes or similar facilities. Design. The study was carried out in a geographically defined area in the south of Sweden. A questionnaire was sent to all the Registered Nurses (n = 314) working within community health care of whom 210 Registered Nurses replied to the questionnaires. Methods. Latent content analysis was used on the comments to six questions, in order to illuminate the statistical findings from the statements of the questions measured by the Likert scale. Results. The results showed that almost half of the Registered Nurses working in care of older people are not satisfied with their working situation. The nurses with less than 5 years working experience find their working situation most stimulating. All of them expressed that it is important that there is co‐operation between themselves and the family members and it was also considered important to develop models that could improve co‐operation. Male nurses believed, to a lesser extent, that family members were a resource in caring, compared with female nurses; however, all male nurses stressed the importance of facilitating informal caregivers. Nurses with more than 5 years of working experience expressed that it was important that family members show engagement in caring for older people. Furthermore, they expressed that it was necessary that the family members took care of the older persons’ interests. Relevance to clinical practice. The findings that half of the Registered Nurses are dissatisfied with their working situation have relevance in clinical practice because of the risk of losing competent nurses in this area.     

Nursing resources on the nursing unit and quality of patient care.

This article deals with the relationships between nursing resources and quality of patient care. The following relationships were found: (1) the quality of the nursing care plan was negatively related to the number of part-time student nurses, full-time Aides, part-time Registered Nurses (RN), and full-time RNs; (2) the quality of the nursing record was negatively related to the number of part-time RNs and full-time student nurses; and (3) the quality of the nursing care at the bedside was negatively related to the number of full-time student nurses and number of patients on the ward; and (4) the total quality of nursing care was negatively related to the number of full-time student nurses, part-time RNs, part-time student nurses, full-time Aides, and full-time RNs. The results were discussed in terms of the effects various nursing resources have on the performance of the RN.     

Developing team based acute care scenarios: A rural hospital experience

BackgroundHealth professionals work in teams in a variety of health care settings especially in medical emergency teams at times of crisis. However, Registered Nurses (RNs) rarely have the chance to partake in educational programs designed for teams of nurses to practice working together in life-threatening situations. Further RN’s employed in rural setting have less opportunities for professional development than their city based counterparts. Simulated scenarios with a patient actor in a rural hospital have been utilised in this study to provide nurses with the opportunity to work as a team in the early recognition and management of patients with acute medical conditions.AimThis discussion paper focuses on one aspect of a larger research project with the aim of describing the development of team based scenarios for a rural hospital setting, focusing on the detection and management of a deteriorating patient.MethodsThree team based scenarios, the related assessments and feedback techniques are all described.ConclusionTeam based simulation provides a unique opportunity to assist registered nurses in rural settings in re-skilling or maintaining their emergency management skills.