Recapturing Total-Person Care

“Why did you want to be a nurse?” is a question that commonly appears on nursing school applications and is often asked during interviews with nursing candidates. In a recent conversation with some of my fellow seasoned nurses, we recalled this essential question and chuckled as we shared our similar responses: “I want to help others,” “I enjoy working with people,” “I see helping people improve their health as special work that I feel called to do.” Although our view of nursing may have been simplistic and naïve, we launched our careers wanting to serve people—not just perform tasks—but to engage with other human beings. We proceeded to learn how to care for the whole person, including their physical, mental, psychosocial, and spiritual needs. Although we performed many procedures to prevent and treat various health conditions, they were components of our multifaceted approach to caring for our patients, but not our sole contribution. The nursing landscape has changed, however. When examining today’s nursing activities in many typical long-term care (LTC) settings, nursing functions are often fragmented, contributing to less emphasis being placed on the people we have been enlisted to serve.

Tasks and Silos

Fragmentation can be found at all points of care in nursing homes. Newly admitted residents are assessed by a coordinator of the Minimum Data Set (MDS), and care plans are often developed without the participation of the frontline caregivers, who spend the most time with residents and come to know them best. When pressure ulcers occur, they are evaluated and treated by a wound care nurse, whereas a resident’s medications are administered by a nurse who may have little to no involvement with the resident beyond this activity. Other services, including ambulation, cognitive stimulation, exercises, feeding, and lifting, may be performed by a host of different staff members, whose only contact with the resident occurs when the activity they are responsible for needs to be performed.

The focus on meeting regulations further fragments care. Regulatory requirements regarding the provision of nursing care in LTC settings are essential, as standards must be met to keep facilities licensed, and more importantly, to provide the foundation for safe care; however, regulations often only ensure that the very basics of care are met. They do not guide holistic or total-person care. Although residents need much more from nursing than is required by regulations, in many situations regulations drive nursing functions.

At the end of the day, tasks must be completed to ensure regulatory compliance is met, but has anyone ensured that residents’ complete needs are being met? Has any single nurse spent a sufficient amount of time with any  resident to identify a subtle change in his or her function, recognize a distressed spiritual state, discover his or her feelings about a recent family visit, or offer comforting words?

The fragmented, task-oriented approach to care is the result of many factors. Historically, nursing home care evolved in a disorganized manner, rather than by following a defined model. There was no leadership that described nursing standards and practice for patients with chronic care needs requiring institutional support. Owners and operators of nursing homes did not develop a model for their settings that considered the holistic needs of the population served and the best strategies to meet them; instead, they looked for the most cost-effective means of satisfying regulations that addressed only basic requirements. Third-party reimbursement barely covered the cost of meeting those basic regulatory requirements, thereby limiting the incentive and ability of owners and operators to develop care models that provide comprehensive, coordinated, and individualized care to residents.

Nursing is hardly blame-free in the development of this problematic approach to care. Nurses, ironically, lacked leadership presence in the development of nursing home care models, despite the use of the profession’s name in the label for this form of care. The voice of nursing was noticeably absent when Medicare and Medicaid were being developed in the 1960s, and when lobbyists for nursing home owners and the American Medical Association were offering Congress direction as to the standards that would enable nursing homes to participate in these reimbursement programs. Even in the subsequent decades, there was no unified voice of protest from nursing professionals when a significant number of nursing homes provided substandard care and were staffed with an inadequate quantity and quality of nurses. Nursing schools provided little, if any, instruction related to the unique aspects of geriatric care, including of chronic diseases and LTC in general, a pertinent consideration since most LTC nurses represent a generation that attended nursing school several decades ago. Efforts to transform the culture of nursing homes to promote higher quality care that is centered on and directed by residents have been led by consumers and disciplines outside of nursing.

Changing the Culture of Care 

There are many fine nurses who provide holistic, well-coordinated professional care, rather than just performing isolated tasks. More of these nurses are needed. LTC nurses must reflect on their typical workday and evaluate if they are engaging with residents sufficiently to assess residents’ physical, mental, emotional, social, and spiritual status; take the time to plan and care for needs that surface; and offer interventions that they are uniquely prepared to provide. Nurses also need to evaluate their own knowledge and skills to ensure they are working from a foundation of current best practices and standards and take personal responsibility for advancing their competencies.

Nursing associations must provide leadership in defining, advocating, and equipping nurses for the unique aspects of LTC nursing. An example of this is a program that the American Association for Long Term Care Nursing (AALTCN) is involved in, intended to bring culture change and quality improvement programming to under-resourced, under-performing nursing homes. Through the program, several of AALTCN’s certification programs are offered to nurses in various roles. Many nurses who have participated in the program have indicated that it gave them clarity about the unique responsibilities and requirements for specific positions in their facility and a true understanding of the meaning of holistic nursing care. By developing programs to prepare LTC nurses for their various roles and providing an effective means to deliver these programs, associations can help enhance competencies. For more information about AALTCN’s programs,
visit https://ltcnursing.org/AALTCN-learning-community.

Many nursing homes currently use nurses to complete MDS forms, treat wounds, and perform other tasks; thus, nurses need to ensure that these functions are well coordinated and that information is exchanged and used to its full potential by all staff. Nurses should work to sharpen and apply their own clinical skills to competently assess, plan, and provide comprehensive care, and should advocate for and demonstrate leadership that clearly defines individualized, total-person care. Nurses can have a positive influence on how their facilities operate and how LTC services are reimbursed.

Dr. Eliopoulos is executive director, American Association for Long Term Care Nursing, Cincinnati, OH.