Structuring Student Placements in the Nursing Home

1. Structuring Student Placements in the Nursing Home Mathy Mezey, EdD, RN, FAAN, Sarah Greene Burger, RN-C, MPH, FAANEthel Mitty, EdD, RN Hartford Institute for Geriatric Nursing, New York University College of Nursing Module 4 of Nursing Homes as Clinical Placement Sites for Nursing Students Series

2. Acknowledgments This is a joint project of With support from Grant to the University of Minnesota School of Nursing

3. This project is endorsed by: Project Steering Committee View List of Members

4. About Module 4: Structuring Student Placements in the Nursing Home Select a nursing home as a clinical placements for nursing students Design student placements in nursing homes in light of student learning goals Organize student exposure to resident-directed care and culture change Analyze resources that can inform student placement in nursing homes: Resources to enhance clinical teaching in nursing homes generally Resources specific to clinical teaching of resident-directed care and culture change General geriatric nursing resources Objectives/Purpose: At the end of this module you will be able to: Please note that Module 4 refers to nursing practice in “typical” nursing homes. For information on nurse practice in nursing homes implementing resident directed care and culture change, see Modules 3 and 5.

5. Faculty should preferentially choose nursing homes for clinical placements that meet nationally recognized standards of high quality care: Nursing homes with a CMS 5 or 4 Star Quality Rating These nursing homes will be in the top 10% of nursing homes nationally and represent the highest quality of care These nursing homes are more likely than others to have higher RN / resident staffing ratios Nursing homes with Joint Commission accreditation Joint Commission accreditation is voluntary; related to nursing home’s managed care relationship and healthcare network requirements Selecting a Nursing Home as a Clinical Placement: General Recommendation 1 Click to view more information on MDS -Module 1: An overview of nursing homes generally and on Nursing Staffing, Module 2: An overview of nursing in nursing homes

6. Selecting a Nursing Home as a Clinical Placement: General Recommendation 2 • Nursing homes with a CMS 1 Star Rating in all likelihood have serious deficiencies in quality of care • Avoid homes with one yellow star, indicating chronic poor care, irrespective of student learning objectives • Nursing homes with CMS 2 and 3 Star Ratings are likely to have deficiencies in important aspects of care and/or staffing • Nursing homes with many and persistent deficiencies should be Avoided • Consider the number and type of deficiencies in relationship to the student learning objectives

7. Options for Student Placement When Nursing Homes with High Quality Ratings are Not Geographically Accessible Collaborate with nursing homes: Workshops for faculty and students Seek CMS 3 & 4 star nursing homes interested in opportunities to improve care Assisted Living Senior Center Continuing Care Retirement Community Naturally Occurring Retirement Community

8. Nursing Faculty Concerns: Nursing Homes as a Clinical Placement • The Director of Nursing (DON) does not have a minimum of a baccalaureate degree in nursing • RNs are not on site during student placement • There is instability in nurse leadership, and nursing staff (RN; LPN; CNA) turnover is very high Click here to learn more: Module 2: An overview of nursing in nursing homes

9. Select placements other than nursing homes Tailor student assignment to nursing home’s staffing strengths and students’ level in the program: Use nursing home for task-oriented assignments (e.g., manual skill acquisition). Assign student to nursing home nursing staff with at least BSN. Assign students to shadow an APN who cares for residents in the nursing home. Options for Student Placements When a Nursing Home with Strong RN Presence is Not Available Click to view more information on MDS: Module 1: An overview of nursing homes generally Click to view more information on Nursing Staffing: Module 2: An overview of nursing in nursing homes

10. Nursing homes engaged in culture change should be preferentially selected as clinical placement sites Identifying culture change nursing homes Self-identified Member of: Pioneer Network (http://www.pioneernetwork.net) Eden Alternative (http://www.edenalt.org) Greenhouse (http://www.thegreenhouseproject.org) Wellspring (http://www.wellspringis.org) Nursing homes can be practicing resident-directed care but not self-identify as a culture change nursing home. Resident-Directed Care and Culture Change Nursing Homes Click here to view content on resident directed care and culture change: Module 3: Content on resident directed care and culture change Click here to view a case-study on culture change and options for introducing culture change concepts when no culture change facilities are geographically available: Module 5: A case study to help faculty introduce resident-directed care and culture change

11. Observe and understand Resident choices and autonomy Issues of resident risk versus safety Licensed nursing role in staff and resident empowerment Leadership style Meet with a primary CNA to learn about resident preferences, how CNAs prioritize and help the resident make decisions Senior/APN student activity/assignment: modify and adapt resident’s care plan based on the resident’s perception of risk taking and safety needs In absence of a culture change nursing home see module 5 Opportunities for Student Learning in Culture Change Nursing Homes Click here to learn more about Resident directed care and culture change: Module 3: Content on resident directed care and culture change Click here to view a case-study on culture change: Module 5: A case study to help faculty introduce resident-directed care and culture change

12. Types of learning objectives Learning objectives related to type of course Learning objectives related to specific content or skills 1, 2 Health systems: Nursing Home Quality Resident attributes/assessment Diagnosis and management Leadership, staffing and organizational assessment Interdisciplinary team Resident directed care and culture change Ethical decision making Policy and reimbursement Nursing Student Learning Objectives

13. Assign student to evaluate overall quality of the nursing home to which they are assigned by comparing with other nursing homes. See websites: www.medicare.gov/NHCompare www.nhqualitycampaign.org Assign student to compare state regulatory variations among states: http://www.hpm.umn.edu/nhregsplus/ Intensify the depth of assignment based on student’s level in the program (i.e. generic juniors, seniors, graduate) Assign students to look at web site: Nursing Home Compare http://www.medicare.gov/NHCompare http://pioneernetwork.org Learning Objective Health systems: NH Quality Sample Student Assignments

14. Learning Objective Health systems: Nursing Home Quality Sample Student Assignments (Cont’d) • Create assignments to meet student learning goals, e.g. communication, policy, interdisciplinary • Assign student to participate in family/resident care plan meeting • “Adopt a resident”: interview resident, family, interdisciplinary team members, staff to create a “collage” of the resident: history, etc. [reminiscence-type therapy] • After soliciting input from nursing staff, have student prepare and present an evidence-based in-service program (e.g., culture change, geriatric syndromes, geriatric resources) • Discussion: why did the facility get a “low” star rating? What were the deficiencies? How were they related to nursing care? How can nursing leadership/management change in order to achieve better outcomes?

15. Learning Objective Resident Attributes/ Assessment Sample Student Assignments Student assignments can consist of the following: Dementia unit: meet learning objectives related to communication Sub-acute care unit: meet learning objectives related to acquiring manual/technical skills (ventilators; tracheostomy care) Interdisciplinary team meetings: meet learning objectives related to understanding team roles Short-stay residents: meet learning objectives for synthesis of patient care management For a description of resident attributes, special care units etc. see: Module 1: An overview of nursing homes generally Module 2: An overview of nursing in nursing homes

16. Assign students to compare the job descriptions of the chief nursing officer in the nursing home, the hospital, in assisted living and in home care Assign students to compare nurse staffing (RN; LPN; CNA) in their nursing home placement with nursing home staffing nationally and in their state (content related to policy) View the Nursing Home Compare Website Assign students to observe the role of the DON, the nurse manager, the CNA (content related to leadership) Assign students to assess the program offered in a nursing home rehabilitation unit verses the rehabilitation program in home care or in a hospital rehab unit Assign student to observe examples of communication within and between different categories/strata of staff (i.e. direction and type of communication) Learning Objective Leadership, Staffing and Organizational Assessment Sample Student Assignments

17. Nursing homes are ideal clinical placements to expose nursing students to an inter-disciplinary team. 1,2 Students should have the opportunity to observe the process and outcomes of an interdisciplinary team meeting. The Interdisciplinary Team in Nursing Homes For more information, click to view Module 1: An overview of nursing homes generally Click here to view the GNEC Module on the interdisciplinary team

18. Observe the role of nurses on the interdisciplinary team Present a resident issue at team meetings Speak with and “shadow” key members of the interdisciplinary team Meet with resident/family prior to team meeting to learn their wishes or concerns Meet with the resident’s CNA to get their view on care needs and/or solutions to problems Learning Objective: Interdisciplinary teams Sample Student Assignments For more information, click on the following links: AGS Geriatric Competences for Inter-disciplinary practice Module 1: An overview of nursing homes generally Module 2: An overview of nursing in nursing homes

19. Determine a resident’s capacity to execute an advance directive Evaluate the extent of resident involvement in their “everyday decisions” (e.g., bathing; eating) Understand how decisions are made to transfer a resident to the hospital Senior level student: In discussion with the resident, evaluate the benefit and burden of potential treatments/interventions1 Learning Objective: Ethics and Decision Making Sample Student Assignments For more information click to view Module 2: An overview of nursing in nursing homes

20. Speak with social workers regarding criteria for nursing home admission and discharge Meet with the MDS coordinator to understand how assessment drives reimbursement Evaluate the quality improvement data collected and distributed to the interdisciplinary team Read and evaluate the NH current quality improvement plan and/or study APN Student Assignment: Evaluate/describe how advocacy groups like NCCNHR and Pioneer Network work to change policy to improve care and quality of life Learning Objective: Policy and Reimbursement Sample Student Assignments For more information click on the following links: Module 1: An overview of nursing homes generally Module 2: An overview of nursing in nursing homes

21. Faculty should: Learn/understand the mission of the nursing home Seek unit staff ‘buy-in”: to the goal and purpose of the placement to assure their awareness of students’ level of knowledge and skills Learn how nursing staff organize their time to provide resident care Identify opportunities for electronic communication Recognize staff and students through established joint “rituals” (e.g. graduations; awards; end of semester luncheons; nurses week celebrations) If possible, spend several hours at the nursing home to: Identify professional roles in the nursing home Understand decision-making practices regarding resident care Understand the culture – and routine(s) – of the nursing home, including time and location of interdisciplinary team conferences Learn the EMR system/ process with which the students will be interacting/involved Adapted with permission of CS Aron., Illinois State University, Mennonite College of Nursing Enhancing Communication with the Nursing Homes to Strengthen the Student Learning Environment

22. Related Resources for Clinical Teaching in Nursing Homes • Weekly Reflection Questions • UNC Charlotte School of Nursing • http://nursing.uncc.edu Elder Project Fairfield University School of Nursinghttp://www.fairfield.edu/son ECLEPs Project College of Nursing, Oregon Health Sciences University http://www.ecleps.org View General Geriatric Nursing Resources

23. Recap: Key Points about Structuring Student Placement in the Nursing Home • All nursing homes are not alike • Use objective criteria as to quality and staffing to help you select a nursing home for student placement • Choose programs within a nursing home to meet specific learning objectives We present the following key points to consider:

24. Please Proceed to the following modules of the SeriesNursing Homes as Clinical Placement Sites for Nursing Students Overview of the Project Module 1: An overview of nursing homes generally Module 2: An overview of nursing in nursing homes Module 3: Content on resident directed care and culture change Module 4: Selecting and structuring clinical placements in nursing homes Module 5: A case study to help faculty introduce resident directed care and culture change Module 6: Strategies to help nursing homes position themselves as clinical placement