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Guest Editorial

July 1, 2004
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Changing Nursing Homes: A New Perspective by Dennis Hayes
GUEST editorial


Changing nursing homes: A new perspective While I commend the thrust of Paul Willging's December 2003 column ("Quality Management Isn't as Tough as It Looks"), I respectfully disagree on two issues.

The first is his use of the term multidisciplinary in lieu of the more appropriate term, interdisciplinary. In practice, multidisciplinary approaches are inherently not team processes. Rather, they represent the many disciplines approaching the resident (patient) from distinct and separate disciplinary orientations. An example of this is the hospital system, the traditional "medical model," in which all the varied disciplines do their own thing, quite independently from each other. Witness, for example, the departmental reports that come from x-ray, lab, radiology, physical therapy, internal medicine, or any other discipline. One need only look to the discipline or departmental reports included in a typical hospital discharge packet to see the duplication and lack of coordination among the many disciplines participating in the care of a hospitalized patient. There is no interdisciplinary communication. Each practitioner or technician records the same background, presenting problem, reason for admission, and current status and then goes on to say what his/her discipline did without regard to what the other disciplines did or, indeed, without even seeing the other disciplines' work! They all write from their own points of view, not benefiting from the views of their colleagues in other disciplines.

In a properly operating nursing home, the MDS and/or the care plan should be the product of coequal teammates' input. That assessment/plan should come from a consensus/discussion approach, rather than from several different and often (if not routinely) conflicting approaches, as seen in the multidisciplinary model. This interdisciplinary approach still does not occur in most nursing homes, but the method is potentially available and the approach possible.

My second concern with Dr. Willging's otherwise excellent column has to do with failure to consider the most fundamental defect in the nursing home's operating model: It is essentially a nursing model. Absent a true effort to eliminate this defect, it is doubtful that any appreciable improvement in nursing homes will occur. Without sounding "antinurse" (in fact, my wife is a nurse)-something I have been accused of when someone has been unprepared to fully hear me out on the matter-I contend that the problem in nursing homes is a problem with a system that has elevated nurses' importance beyond reason.

As important as nurses are, they predominate everything in the nursing home, just as doctors predominate everything in the hospital (which isn't working terribly well, either). Quite frankly, nurses have been made to believe that they run the facility. They tell laundry and housekeeping what to do. They also tell social workers, dietitians, and activities directors what to do even though they might know little about any of these professionals' areas.

This "nursing model" might be even more problematic than the multidisciplinary approach because, in fact, it often is a monodisciplinary approach! Therefore, if we ever hope to achieve high quality of care and, hence, customer satisfaction, we have to do the following:

1. Equalize both pay and status for all disciplines. Why is a high school grad with some 15 additional months of training (an LPN) worth $20 per hour or more? Why, especially, is that so when a 150-bed facility might have as many as 20 of these LPN positions? At the same time, this same facility might have a single MSW, perhaps with one assistant (BSW), and they are being paid $15 and $12 per hour, respectively. And consider that these many high-paid LPNs are regularly asking the MSW to serve as a clothing clerk, an eyeglass fixer, or a doctor's appointment maker.

Similarly, activities professionals are paid $15 per hour, even though they might have master's degrees. But they are told to transport residents, go on clinic appointments, and clean up after meals. It begs the question: From whom will quality of care more likely come? From the nurse who passes pills and seldom is really able to even speak to residents, or from the activities director who provides age-appropriate activities and strives to eliminate boredom for those confined to a "home" they never bought or wanted? Or from the social worker who helps elderly residents cope with sexuality urges, grief, and their struggle to exercise any remaining independence? Or is it the from dietitian who struggles to balance eating and nutritional issues for the medically fragile client?

To be sure, we need licensed nurses, but the fact is that these individuals have few assessment skills and do little actual assessment and even less care planning. They are, for all intents and purposes, little more than dispensers of medications and treatments. Nevertheless, they're more highly paid than the people who have more training and more interaction with the residents.

How does this inequity in both status and pay contribute to a sense of team? How does it contribute to a quality organization? The old nursing model, in which nurses predominate over other team members, is no longer (if it ever was) appropriate.