Nationwide there are currently 16,000 certified nursing homes caring for 1.4 million residents (Zhao & Haley, 2011). Due to high nurse turnover rates and persistent staffing shortages, many nursing homes utilize nurse staffing agencies to meet staffing needs. Holliswood Care Center (HCC), a 300 bed nursing home, with five residential floors, located in Hollis, New York is not exempt from such staffing challenges. In fact, according to Yves Pascal, Director of Nursing (DNS) at HCC, “Usually, 2-3 LPN’s per shift are required daily” (Y. Pascal, personal communication, December 15, 2013). Agency nurses are approved to work at HCC once they submit a current physical and complete an in-house facility orientation. During this orientation, agency nurses receive New York State mandated in-services, such as patient abuse and HIPPA. The nurses also receive specific instruction regarding emergency procedures, medication policy, employee conduct and procedures. However, specific unit policies and procedures, location of specific supplies are not included in the general orientation. Upon completion of the orientation, the agency nurse receives no further orientation or precepting. Thus when an agency nurse enters HCC for their first shift they are functioning independently and with limited knowledge. This is clearly a problem, which varies in degree of potential danger to patients based on the specific unit assignment. For instance, on the 7-3 shift there are 2 nurses per floor, a charge nurse and a secondary nurse. In this situation, new agency nurses have an opportunity to work in close cooperation, ask questions and seek guidance from a more seasoned and knowledgeable nurse. In contrast, the 3-11 and 11-7 shifts consist of a single nurse on each unit. The agency nurse’s main source of support is a single RN Supervisor whose responsibility is to provide nursing supervision for the entire facility. Therefore, agency nurses may find it stressful and challenging as they begin to work at HCC and for an inexperienced agency nurse, employment at HCC can be downright disastrous for the nurse and patient. While the agency nurse orientation procedure has been in place for over 25 years, only recently with the sale of HCC to new owners has this procedure become a problem. The previous owner and administrator, Mr. and Mrs. Ahuja, used one staffing agency, Match One Staffing, for many years which provided competent and regular agency nurses. The new owners have sought to increase profits by using staffing agencies based on competitive bidding, which has resulted in a supply of inexperienced nurses.
The problems with inadequate orientation and lack of experience are reflected in unit administrative task failures and poor clinical outcomes. While no systematic in-house study has been conducted to determine the specific rates and outcomes associated with new agency nurses, anecdotal information from nursing management provides an overview of the problem. RN supervisor, Nathalie Francios, who supervises the 3-11 and 11-7 shifts, reports late medications, medication errors, missed or incomplete treatments, poor time management leading to delays in assessment and care, poor performance in emergency situations and inadequate assessment skills (N. Francois, personal communication, December 15, 2013). Ms. Francois shared an experience with an agency nurse who worked the psychiatric unit on the 11-7 shift (N. Francois, personal communication, December 15, 2013). The nurse called Ms. Francois and reported a patient was complaining of feeling restless and anxious. Ms. Francois who was caring for another resident who had just fallen, provided clear directions to the agency nurse. Ms. Francois instructed the nurse to “Assess the patient’s vital signs, obtain an oxygen saturation level and determine if the patient received their 6am Ativan”. According to Ms. Francois, the nurse reported she would check and call right back. Five minutes later Ms. Francois went to the unit to assess the patient, the patient was not breathing and a full code was initiated. Ms. Francois determined upon questioning the nurse that she never checked vital signs due to looking for the pulse oximeter. The patient was subsequently revived and transferred to the hospital via ambulance. This situation, illuminates the issues with using agency nurses who lack adequate and specific unit orientation, the experience and the required competency required to utilize critical judgment and function autonomously on a unit. In summary, the use of agency nurses is often unavoidable, however to facilitate the highest and most effective level of care for residents, HCC must change their agency nurse orientation procedure. The revised agency nurse orientation procedure must include specific unit based information and ensure competency level appropriate to the skill required at HCC.
A2a) Basis for Practice
The current orientation procedure for agency staff nurses was established by the former Owner/Administrator and current DNS, Yves Pascal. According to Smith (2012), “One role of the nursing home administrator is to run the facility based on state standards and to develop policies and procedures that are in line with federal and state requirements.” At the inception of the agency nurse orientation policy, the administrator and the DNS designed a procedure that would meet minimal standards in compliance with state and federal laws. It is the DNS’s responsibility to ensure nurses possess the clinical competency, support and resources to provided effective nursing care. The DNS’s role regarding the orientation procedure is to tailor an orientation in cooperation with the in-service coordinator that meets the needs of the specific facility, unit and patients. However, as previously discussed