RESEARCH TO PRACTICE
Effects of staff assignment and work shift
Burgio L.D.,Fisher, S.E.,Fairchild, J.K.,Scilley K., Hardin, J.M. (2004). Quality of care in the nursing home: Effects of staff assignment and work shift. The Gerontologist, 44, (3), 368-377.
Nursing home residents require assistance from staff to complete many activities of daily living, like bathing, toileting, dressing, etc. This assistance is mainly provided by certified nursing assistants (CNAs), and their job performance is likely to have the greatest impact on residents’ quality of care.
The two most common types of staffing patterns used in nursing homes across the U.S. are permanent assignment and rotating assignment. In permanent assignment (PA) the same staff members are assigned to the same residents every day. This model is the foundation of a person-centered model of care and a hallmark of culture change. It is based on the idea that staff members working with the same residents form strong relational bonds with those residents and can better assist them by anticipating their needs. Rotating assignment (RA) is the model where the main focus is on the care tasks that need to be provided to residents. A team of CNAs rotates among residents according to a predetermined schedule. One of the reasons given by administration for using this model is a fair distribution of “difficult” and “care intensive” residents among staff. The primary goal is to minimize staff turnover rate by preventing staff from being too burdened by taking care of such residents.
Many studies demonstrate the positive effects of the PA model for CNAs and residents. CNAs report increased feelings of personal control and choice. They believe that they provide residents with better care, are more aware of residents’ needs, and have a greater sense of self-efficacy. Even though CNAs’ absenteeism is higher in the PA model, staff report higher job satisfaction in comparison to the RA model’s staff. However, the PA nurses aids also report being more bored with the care routine. They also note that over time some residents become more demanding.
Research also identifies benefits for residents cared for by a consistent team of CNAs. It shows a decrease in disruptive behavior among residents and an increase in their health outcomes. After a year of using the PA model a reduction in decubitus ulcers and increases in the functional ability of residents are shown.
Surveys conducted with residents, their family members, and front-line workers show that all three groups prefer PA staffing. Residents and their families are more comfortable with the continuity of care and know the primary caregiver better. CNAs experience a greater sense of responsibility and increased job satisfaction.
Burgio and his research team (2004) studied PA and RA models of care by observing four nursing homes in Alabama. Two of them self-identified as using the PA model and two others as using the RA model. Day and evening shifts were studied separately. These shifts typically vary in staff-to-resident ratios, and staff turnover is generally higher on the evening shift which disrupts the PA model of care.
Burgio identified that in the observed PA model residents received care from their primary CNAs 50% of the time versus 26% of the time in the RA model. They found that in their studies neither model demonstrated clear superiority in the quality of care measures. The measures examined the quantity and quality of CNA-resident interactions, resident behavioral disturbance; affect states, and personal appearance and hygiene. However, residents in the observed homes were assigned to their primary CNAs only about half the time. The researchers assume that a higher level of care would be seen with more permanent CNA-resident matches. The scores for personal hygiene and personal appearance of residents were significantly higher in PA homes.
Burgio’s study shows differences between day and evening shift; residents exhibited more disruptive behavior and were less engaged during evening shifts than during the day shifts. PA residents show more sadness and less interest during the evening shift. Burgio suggested that this was the residents’ reaction to the absence of the familiar CNA with whom they spend most of their waking hours. The RA residents displayed more sadness during the morning shifts. More morning CNAs report burnout and absenteeism; however, the turnover rate is higher for evening shift workers. Nevertheless, staff from both shifts reported similar job satisfaction. When the models of staffing were compared, staff from the PA model expressed higher job satisfaction than staff from the RA model.
Implications: Many nursing homes have adopted the PA model and many report almost instant benefits reflected in higher quality of care for residents and increased job satisfaction for staff. In order to attain the benefits associated with this model consistency in CNA and resident assignment has to be maintained as much as possible on both the day and the evening shifts. The transition from a RA model into a PA model requires intensive staff re-training. However, the benefits of permanent assignment outweigh the difficulties of the transition.