essay on nursing homes

97 Nursing Home Essay Topic Ideas & Examples

🏆 best nursing home topic ideas & essay examples, 📌 simple & easy nursing home essay titles, 🔎 most interesting nursing home topics to write about, ❓ nursing home research questions.

• Issue of Falls at a Nursing Home: Professional Reflection The problem of patients’ falls in nursing homes is an urgent nursing issue, and my experience in one of these institutions in New Zealand is the object of evaluation.
• Quality Costs for Building a Dementia Nursing Home Firstly, there will be the inclusion of the appraisal costs which entails the inspection and measurement of activities when the operation is ongoing to determine their conformity to the required standards.
• Older Patients’ Transition From a Hospital to a Nursing Home The example of transition of care chosen for further exploration is concerned with the transition of care from the hospital to the nursing home setting for patients that came to receive healthcare for various conditions.
• The Rehabilitation Center and Nursing Home During the evaluation process, the nurse leader identifies the problems in the organization and determines the strong and weak points, resources, gaps, and other factors that determine how the project will develop.
• A Nitrogen Gas Accident at a Nursing Home The nursing home workers failed to recognize this error and did not check the gas before hooking the tanks to the system.
• Regulation of a Large For-Profit Nursing Home Chain To solve the problem of unlawful actions of the stakeholders in nursing homes, there is a need for the implementation of the practical management theory.
• “Implementation and Effects of MRC in a Nursing Home” by Henskens The research’s dependent variable is the outcome to be measured the treatment’s impact on the aforementioned patients’ ADL and QoL. However, the researchers did not provide a clear delineation of the above-mentioned variables in the […]
• Nursing Home Beds: Fundamental Uncertainty and Values If it is assumed that the admission will stay the same, the decision to dismiss a certain amount of employees will reduce fixed costs in both facilities.
• A Nursing Home Working Scenario Working in nursing homes has its opportunities and challenges; therefore, the paper will cover the multidisciplinary teams’ working scenario, their interaction and diversity, communication in client care, and support accorded to clients considering their family, […]
• Nursing Home Blueprint and Requirements The aim of the facility should be geared towards the promotion of the health of the old patients through the prevention and treatment of diseases and disabilities.
• Departmental Budget Preparation for Nursing Home However, while the total population in our area of operation is expected to decrease, the population of people who are above 65 years in the US is projected to rise.
• Northern Cochise Nursing Home: Federal and State Surveys Following the findings of the health inspection carried out by Arizona Department of Health Services, the management of the Northern Cochise Nursing home took immediate steps to correct the deficiencies.
• Redondo Nursing Home: Providing Above Average Care While the potential resident and family members are expected to disclose all information pertaining to medical conditions, the planner is required to provide a complete description of the home.
• Organization Strategic Plan for a 40 Bed Nursing Home Unit The core values are to ensure that a team of the highest quality and honesty in delivering services attends to all.
• Activities Coordinator and a Conflict of Interest Situation at Cooinda Nursing Home It is thereby imperative that the practitioner adhere to the guidelines set by the home in such regards because he needs to check how his values and emotions are at par with the organizations, and […]
• Satisfaction With a Transitional Nursing Home Project The abstract does mention the dependant variable of the study viz.satisfaction with the transitional program; it does not, however, mention and discusses the various dimensions of the dependant variable that were measured in order to […]
• Nursing Home Designs: Health and Wellness of Aging The Eden Alternative is a nursing home model of care that places decision-making power into the hands of its clients and their families.
• Future Care Nursing Home in Baltimore City In the United States, up to one-half of the citizens will spend at least a few years of their lives in a nursing home.
• Healthcare Research at Pearl City Nursing Home I can conclude that the methods used in our work are effective and improve the quality of patient care in the Pearl City Nursing Home.
• Nursing Home and Its Impact on Lifespan A nursing home is a special nursing facility where the old, the mentally, and the physically challenged or handicapped people in society are taken care of.
• Choosing an Adult Foster Home or a Nursing Home A nursing home is well known to health and social services professionals as the long-term care service for older adults that accounts for that vast majority of public funding.
• Blumberg’s Nursing Home’s Staffing Crisis The present paper will seek to assess the current needs of the facility and develop a useful HR policy for inappropriate conduct.
• Blumberg’s Nursing Home: Staffing Crisis The situation under analysis is complicated due to the level of awareness and the necessity to take immediate steps and fill the unstaffed positions.
• Employee Compensation and Benefits. Senior Secretary at Capital Nursing Home Limited The proposal demonstrates that the value of the employee’s benefits augmented with the annual salary and provides the total compensation. The total compensation package for the position of Senior Secretary includes the base pay and […]
• Fernhill Nursing Home Run by Colten Care Limited Staff management for my team is my responsibility; and of course I am a nurse so my basic role is providing general nursing care to the residents and any other role that might be allocated […]
• Reduce Hospitalization of Nursing Home Residents Publicity of INTERACT as a program having the necessary infrastructure and leadership commitment in health care matters for the elderly is one promising way that can be used to overcome these issues.
• The Effects of Group Music Making on the Wellbeing of Nursing Home Residents
• Assessing French Nursing Home Efficiency
• Assessing Nursing Home Care Quality Through Bayesian Networks
• Can Family Caregiving Substitute for Nursing Home Care
• Cost (In)Efficiency and Institutional Pressures in Nursing Home Chains
• The Difference Between Nursing Homes and Retirement Homes
• Direct Care Workers’ Response to Dying and Death in the Nursing Home
• Does Paid Family Leave Reduce Nursing Home Use
• Economic Disability and Health Determinants of the Hazard of Nursing Home Entry
• Effective Human Resources Leadership for Nursing Home
• Elder Abuse Within Nursing Home Setting
• Elderly Falls Within the Nursing Home
• End-Of-Life Decision Making for Nursing Home Residents With Dementia
• Impact of Family Structure on the Risk of Nursing Home Admission
• Nursing Home Facility Versus a General Acute Care Hospital
• Improving Wound and Pressure Area Care in a Nursing Home
• Nursing Home Environment and Pet Therapy Programs
• The Effects of 1935’s Social Security Act on the Nursing Home Industry
• Nursing Home Care Versus Assisted Living Care
• Health Care Utilization Nursing Home Administration
• Nursing Home Staff Turnover and Better Practices
• Mental Disorders Among Non-Elderly Nursing Home Residents
• Forecasting Nursing Home Utilization of Elderly Americans
• Incorporating Quality Into Data Envelopment Analysis of Nursing Home Performance
• Interventions That Encourage High-Value Nursing Home Care
• Lateral Violence and Uncivil Behavior in a Nursing Home
• Medicaid and the Cost of Improving Access to Nursing Home Care
• Medicaid Reimbursement and the Quality of Nursing Home Care
• Who Makes the Decision to Go to a Nursing Home
• Understanding the Medical Aspect of a Nursing Home
• The Fate and Welfare of Nursing Home Residents
• The Social Security Act of Nursing Home Facilities
• Physical Restraint in Nursing Home Facilities
• Predicting Nursing Home Utilization Among the High-Risk Elderly
• How Many Nursing Home Residents Live With a Mental Illness
• Improving the Nursing Home: A Framework for Professional Nursing Practice
• Incapacitated vs. Incompetence: Employees in the Nursing Home Industry
• An Argument in Enhancing the Care Quality in a Nursing Home
• How to Prevent Accidents in Nursing Homes
• Positive and Negative Views of Nursing Homes
• What Are the Benefits of Living in a Nursing Home?
• Do People Live Longer at Home or in a Nursing Home?
• What Is the Main Purpose of a Nursing Home?
• Why Is Assisted Living Better Than a Nursing Home?
• Which Are the Most Important Problems of Nursing Home Residents?
• How Do You Know When Someone Is Ready for a Nursing Home?
• What Participation and Knowledge Are Associated with Nursing Home Admission Decisions Among the Working-Age Population?
• Is It Bad to Put Your Parents in a Nursing Home?
• What Is the Most Common Diagnosis in Nursing Homes?
• How Did the Social Security Act of 1935 Affect the Nursing Home Industry?
• Can a Doctor Put Someone in a Nursing Home?
• How Can You Improve the Quality of Life in a Nursing Home?
• What Are the Most Common Reasons Seniors Are Placed in a Nursing Home?
• Are Nursing Homes Better Than Care Homes?
• What Is the Difference Between a Nursing Home and a Senior Home?
• How Can the Risk of Violence in Nursing Homes Be Reduced?
• What Are the Perspectives and Expectations of Telemedicine Opportunities from Families of Nursing Home Residents and Nursing Home Caregivers?
• How Do You Deal with the Guilt of Putting Your Parents in a Nursing Home?
• What Percentage of Nursing Home Residents Are Depressed?
• Is a Nursing Home the Best Choice for the Elderly?
• What Are the Physical, Intellectual, Emotional, and Social Benefits of Various Stimulating Activities for Nursing Home Residents?
• How to Deal With Collateral Violence and Indecent Behavior in a Nursing Home?
• What Are Nursing Home Residents’ Views on Dying and Death?
• How Often Should You Visit Your Mother in a Nursing Home?
• What Is the Difference Between a Residential Care Home and a Nursing Home?
• Should Elderly Parents Live in a Nursing Home or Not?
• What Is the Social Security Act of Nursing Home Facilities?
• How Can Human Resources Improve Nursing Home Management?
• What Are the Disadvantages of Living in a Nursing Home?
• How Important Is the Medical Aspect of a Nursing Home?
• Chicago (A-D)
• Chicago (N-B)

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128 Nursing Home Essay Topic Ideas & Examples

Inside This Article

Nursing homes play a vital role in providing care for the elderly and individuals with disabilities who are unable to live independently. As a student studying nursing or healthcare, you may be required to write essays on various topics related to nursing homes. To help you get started, here are 128 nursing home essay topic ideas and examples.

• The importance of quality care in nursing homes
• Challenges faced by nursing homes in providing care for residents
• The role of nurses in nursing homes
• Strategies for improving communication between staff and residents in nursing homes
• The impact of COVID-19 on nursing homes
• Ethical considerations in nursing home care
• The benefits of music therapy for residents in nursing homes
• The role of social workers in nursing homes
• Addressing the mental health needs of residents in nursing homes
• The impact of technology on nursing home care
• Strategies for preventing falls in nursing homes
• The benefits of pet therapy in nursing homes
• The challenges of caring for residents with dementia in nursing homes
• The importance of cultural competence in nursing home care
• Strategies for promoting independence in nursing home residents
• The role of occupational therapy in nursing homes
• Addressing the nutritional needs of residents in nursing homes
• The impact of staff turnover on nursing home care
• The benefits of art therapy for residents in nursing homes
• Strategies for preventing and addressing elder abuse in nursing homes
• The role of family members in the care of nursing home residents
• The benefits of physical therapy for residents in nursing homes
• The challenges of providing end-of-life care in nursing homes
• Strategies for improving medication management in nursing homes
• The impact of staffing ratios on nursing home care
• The benefits of reminiscence therapy for residents in nursing homes
• Addressing the spiritual needs of residents in nursing homes
• The role of case managers in nursing homes
• Strategies for promoting socialization among residents in nursing homes
• The impact of regulatory requirements on nursing home care
• The benefits of aromatherapy for residents in nursing homes
• Addressing the needs of LGBTQ+ residents in nursing homes
• The role of physical activity in promoting health and well-being in nursing home residents
• Strategies for addressing the needs of residents with chronic pain in nursing homes
• The impact of social isolation on residents in nursing homes
• The benefits of gardening therapy for residents in nursing homes
• Addressing the needs of residents with developmental disabilities in nursing homes
• The role of recreational therapy in nursing homes
• Strategies for promoting dignity and respect for residents in nursing homes
• The impact of dementia-friendly design on nursing home care
• The benefits of mindfulness therapy for residents in nursing homes
• Addressing the needs of residents with substance use disorders in nursing homes
• The role of speech therapy in nursing homes
• Strategies for promoting staff wellness in nursing homes
• The impact of music and memory programs on residents in nursing homes
• The benefits of animal-assisted therapy for residents in nursing homes
• Addressing the needs of residents with traumatic brain injuries in nursing homes
• The role of dietitians in nursing homes
• Strategies for promoting cultural diversity in nursing homes
• The impact of environmental design on nursing home care
• The benefits of horticulture therapy for residents in nursing homes
• Addressing the needs of residents with visual impairments in nursing homes
• The role of psychologists in nursing homes
• Strategies for promoting resident empowerment in nursing homes
• The impact of technology on resident engagement in nursing homes
• The benefits of sensory stimulation for residents in nursing homes
• Addressing the needs of residents with hearing impairments in nursing homes
• The role of chaplains in nursing homes
• Strategies for promoting staff communication and collaboration in nursing homes
• The impact of person-centered care on nursing home residents
• The benefits of laughter therapy for residents in nursing homes
• Addressing the needs of residents with mobility impairments in nursing homes
• The role of pharmacists in nursing homes
• Strategies for promoting resident rights in nursing homes
• The impact of intergenerational programs on residents in nursing homes
• The benefits of art and music programs for residents in nursing homes
• Addressing the needs of residents with intellectual disabilities in nursing homes
• The role of physical environment in promoting resident well-being in nursing homes
• Strategies for promoting staff retention in nursing homes
• The impact of music and movement programs on residents in nursing homes
• The benefits of aromatherapy for residents with anxiety in nursing homes
• Addressing the needs of residents with post-traumatic stress disorder in nursing homes
• The role of nutrition in promoting resident health and well-being in nursing homes
• Strategies for promoting resident autonomy and decision-making in nursing homes
• The impact of resident engagement in activities on overall well-being in nursing homes
• The benefits of pet therapy for residents with depression in nursing homes
• Addressing the needs of residents with bipolar disorder in nursing homes
• The role of recreational therapy in promoting resident socialization in nursing homes
• Strategies for promoting resident safety in nursing homes
• The impact of resident satisfaction on quality of care in nursing homes
• The benefits of mindfulness meditation for residents in nursing homes
• Addressing the needs of residents with schizophrenia in nursing homes
• The role of social workers in advocating for resident rights in nursing homes
• Strategies for promoting resident engagement in decision-making in nursing homes
• The impact of resident-centered care on quality of life in nursing homes
• The benefits of art therapy for residents with dementia in nursing homes
• Addressing the needs of residents with autism spectrum disorders in nursing homes
• The role of occupational therapy in promoting resident independence in nursing homes
• Strategies for promoting resident well-being through environmental design in nursing homes
• The impact of resident empowerment on overall quality of care in nursing homes
• The benefits of music therapy for residents with Alzheimer's disease in nursing homes
• Addressing the needs of residents with Parkinson's disease in nursing homes
• The role of physical therapists in promoting resident mobility in nursing homes
• Strategies for promoting resident engagement in physical activity in nursing homes
• The impact of resident-centered care on staff satisfaction in nursing homes
• The benefits of reminiscence therapy for residents with communication difficulties in nursing homes
• Addressing the needs of residents with aphasia in nursing homes
• The role of speech therapists in promoting resident communication in nursing homes
• Strategies for promoting resident engagement in social activities in nursing homes
• The impact of resident-centered care on resident outcomes in nursing homes
• The benefits of music therapy for residents with depression in nursing homes
• Addressing the needs of residents with anxiety disorders in nursing homes
• The role of recreational therapists in promoting resident well-being in nursing homes
• Strategies for promoting resident engagement in leisure activities in nursing homes
• The impact of resident-centered care on family satisfaction in nursing homes
• The benefits of art therapy for residents with PTSD in nursing homes
• Addressing the needs of residents with eating disorders in nursing homes
• The role of dieticians in promoting resident nutrition in nursing homes
• Strategies for promoting resident engagement in meal planning and preparation in nursing homes
• The impact of resident-centered care on resident satisfaction in nursing homes
• The benefits of music therapy for residents with schizophrenia in nursing homes
• The role of psychologists in promoting resident mental health in nursing homes
• Strategies for promoting resident engagement in cognitive activities in nursing homes
• The impact of resident-centered care on resident quality of life in nursing homes
• The benefits of art therapy for residents with developmental disabilities in nursing homes
• Addressing the needs of residents with physical disabilities in nursing homes
• Strategies for promoting resident engagement in physical therapy in nursing homes
• The impact of resident-centered care on resident independence in nursing homes
• The role of occupational therapists in promoting resident independence in nursing homes
• Strategies for promoting resident engagement in occupational therapy in nursing homes

These nursing home essay topic ideas and examples cover a wide range of issues related to nursing home care. Whether you are writing a research paper, reflective essay, or informative piece, these topics can help you explore different aspects of nursing home care and contribute to the ongoing discussion on how to improve the quality of care for residents in nursing homes.

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How to Write a Nursing Essay with a Quick Guide

Ever felt the blank-page panic when assigned a nursing essay? Wondering where to start or if your words will measure up to the weight of your experiences? Fear not, because today, we're here to guide you through this process.

Imagine you're at your favorite coffee spot, armed with a cup of motivation (and maybe a sneaky treat). Got it? Great! Now, let's spill the secrets on how to spin your nursing tales into words that not only get you that A+ but also tug at the heartstrings of anyone reading. We've got your back with nursing essay examples that'll be your inspiration, an outline to keep you on the right path, and more!

What Is a Nursing Essay

Let's start by dissecting the concept. A nursing essay serves as a focused exploration of a specific aspect of nursing, providing an opportunity for students to demonstrate their theoretical knowledge and its practical application in patient care settings.

Picture it as a journey through the challenges and victories of a budding nurse. These essays go beyond the classroom, tackling everything from tricky ethical dilemmas to the impact of healthcare policies on the front lines. It's not just about grades; it's about proving, 'I'm ready for the real deal.'

So, when you read or write a nursing essay, it's not just words on paper. It's like looking into the world of someone who's about to start their nursing career – someone who's really thought about the ins and outs of being a nurse. And before you kick off your nursing career, don't shy away from asking - write my essay for me - we're ready to land a professional helping hand.

How to Start a Nursing Essay

When you start writing a nursing essay, it is like gearing up for a crucial mission. Here's your quick guide from our nursing essay writing service :

Choosing Your Topic: Select a topic that sparks your interest and relates to real-world nursing challenges. Consider areas like patient care, ethical dilemmas, or the impact of technology on healthcare.

Outline Your Route : Plan your essay's journey. Create a roadmap with key points you want to cover. This keeps you on track and your essay on point.

Craft a Strong Thesis: Assuming you already know how to write a hook , kick off your writing with a surprising fact, a thought-provoking quote, or a brief anecdote. Then, state your main argument or perspective in one sentence. This thesis will serve as the compass for your essay, guiding both you and your reader through the rest of your writing.

How to Structure a Nursing Essay

Every great essay is like a well-orchestrated performance – it needs a script, a narrative that flows seamlessly, capturing the audience's attention from start to finish. In our case, this script takes the form of a well-organized structure. Let's delve into the elements that teach you how to write a nursing essay, from a mere collection of words to a compelling journey of insights.

Nursing Essay Introduction

Begin your nursing essay with a spark. Knowing how to write essay introduction effectively means sharing a real-life scenario or a striking fact related to your topic. For instance, if exploring patient care, narrate a personal experience that made a lasting impression. Then, crisply state your thesis – a clear roadmap indicating the direction your essay will take. Think of it as a teaser that leaves the reader eager to explore the insights you're about to unfold.

In the main body, dive into the heart of your essay. Each paragraph should explore a specific aspect of your topic. Back your thoughts with examples – maybe a scenario from your clinical experience, a relevant case study, or findings from credible sources. Imagine it as a puzzle coming together; each paragraph adds a piece, forming a complete picture. Keep it focused and let each idea flow naturally into the next.

Nursing Essay Conclusion

As writing a nursing essay nears the end, resist the urge to introduce new elements. Summarize your main points concisely. Remind the reader of the real-world significance of your thesis – why it matters in the broader context of nursing. Conclude with a thought-provoking statement or a call to reflection, leaving your reader with a lasting impression. It's like the final scene of a movie that leaves you thinking long after the credits roll.

Nursing Essay Outline

Before diving into the essay, craft a roadmap – your outline. This isn't a rigid skeleton but a flexible guide that ensures your ideas flow logically. Consider the following template from our research paper writing service :

Introduction

• Opening Hook: Share a brief, impactful patient care scenario.
• Relevance Statement: Explain why the chosen topic is crucial in nursing.
• Thesis: Clearly state the main argument or perspective.

Patient-Centered Care:

• Definition: Clarify what patient-centered care means in nursing.
• Personal Experience: Share a relevant encounter from clinical practice.
• Evidence: Integrate findings from reputable nursing literature.

Ethical Dilemmas in Nursing Practice

• Scenario Presentation: Describe a specific ethical challenge faced by nurses.
• Decision-Making Process: Outline steps taken to address the dilemma.
• Ethical Frameworks: Discuss any ethical theories guiding the decision.

Impact of Technology on Nursing

• Current Trends: Highlight technological advancements in nursing.
• Case Study: Share an example of technology enhancing patient care.
• Challenges and Benefits: Discuss the pros and cons of technology in nursing.
• Summary of Key Points: Recap the main ideas from each section.
• Real-world Implications: Emphasize the practical significance in nursing practice.
• Closing Thought: End with a reflective statement or call to action.

A+ in Nursing Essays Await You!

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Nursing Essay Examples

Here are the nursing Essay Examples for you to read.

Writing a Nursing Essay: Essential Tips

When it comes to crafting a stellar nursing essay, a few key strategies can elevate your work from ordinary to exceptional. Here are some valuable tips from our medical school personal statement writer :

Connect with Personal Experiences:

• Approach: Weave personal encounters seamlessly into your narrative.
• Reasoning: This not only adds authenticity to your essay but also serves as a powerful testament to your firsthand understanding of the challenges and triumphs in the nursing field.

Emphasize Critical Thinking:

• Approach: Go beyond describing situations; delve into their analysis.
• Reasoning: Nursing essays are the perfect platform to showcase your critical thinking skills – an essential attribute in making informed decisions in real-world healthcare scenarios.

Incorporate Patient Perspectives:

• Approach: Integrate patient stories or feedback into your discussion.
• Reasoning: By bringing in the human element, you demonstrate empathy and an understanding of the patient's experience, a core aspect of nursing care.

Integrate Evidence-Based Practice:

• Approach: Support your arguments with the latest evidence-based literature.
• Reasoning: Highlighting your commitment to staying informed and applying current research underscores your dedication to evidence-based practice – a cornerstone in modern nursing.

Address Ethical Considerations:

• Approach: Explicitly discuss the ethical dimensions of your topic.
• Reasoning: Nursing essays provide a platform to delve into the ethical complexities inherent in healthcare, showcasing your ability to navigate and analyze these challenges.

Balance Theory and Practice:

• Approach: Connect theoretical concepts to real-world applications.
• Reasoning: By bridging the gap between theory and practice, you illustrate your capacity to apply academic knowledge effectively in the dynamic realm of nursing.

Highlight Interdisciplinary Collaboration:

• Approach: Discuss collaborative efforts with other healthcare professionals.
• Reasoning: Acknowledging the interdisciplinary nature of healthcare underscores your understanding of the importance of teamwork – a vital aspect of successful nursing practice.

Reflect on Lessons Learned:

• Approach: Conclude with a thoughtful reflection on personal growth or lessons from your exploration.
• Reasoning: This not only provides a satisfying conclusion but also demonstrates your self-awareness and commitment to continuous improvement as a nursing professional.

As we wrap up, think of your essay as a story about your journey into nursing. It's not just about getting a grade; it's a way to share what you've been through and why you want to be a nurse.

Imagine the person reading it – maybe a teacher, a future coworker, or someone starting their nursing journey. They're trying to understand your passion and why you care about nursing.

So, when you write, remember it's more than just an assignment. It's your chance to show why nursing matters to you. And if you ever need help – there's always support from our essay writer online .

Ready to Excel in Your Nursing School Essay?

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How to Write a Nursing Essay?

How can a nursing essay effectively address ethical considerations, what are some examples of evidence-based practices in nursing essays.

Daniel Parker

is a seasoned educational writer focusing on scholarship guidance, research papers, and various forms of academic essays including reflective and narrative essays. His expertise also extends to detailed case studies. A scholar with a background in English Literature and Education, Daniel’s work on EssayPro blog aims to support students in achieving academic excellence and securing scholarships. His hobbies include reading classic literature and participating in academic forums.

is an expert in nursing and healthcare, with a strong background in history, law, and literature. Holding advanced degrees in nursing and public health, his analytical approach and comprehensive knowledge help students navigate complex topics. On EssayPro blog, Adam provides insightful articles on everything from historical analysis to the intricacies of healthcare policies. In his downtime, he enjoys historical documentaries and volunteering at local clinics.

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Nurses Deserve Better. So Do Their Patients.

By Linda H. Aiken

Dr. Aiken is a professor of nursing and sociology and the founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

The Covid-19 pandemic exposed strengths in the nation’s health care system — one of the greatest being our awesome nurses. But it also exposed many weaknesses, foremost among them being chronic nurse understaffing in hospitals , nursing homes and schools .

More nurses died of job-related Covid than any other type of health care worker. The more than 1,140 U.S. nurses who lost their lives in the first year of the pandemic knew the risks to themselves and their families. And yet they stayed in harm’s way. They cared for their fallen co-workers. They went to New York from around the country to fight on the front lines in the first Covid surge. Nurses from Northwell Health in New York returned that support by deploying to the Henry Ford Health System in Detroit in December when a surge occurred there.

We celebrate nurses now. We call them heroes. But if we value their sacrifices and want them to be there when we need them, we must prevent a return to the poor prepandemic working conditions that led to high nurse burnout and turnover rates even before Covid.

As a nurse with extensive clinical experience in hospitals, I found it nearly impossible to guarantee safe, effective and humane care to my patients. And so I established the world’s leading research center on nursing outcomes to understand the causes of nurse understaffing in the United States and abroad and to find solutions to the problem.

The United States has a robust supply of nurses . And there is no evidence that recruits to nursing have been deterred by Covid. To the contrary, applications to nursing schools increased during the pandemic.

Death, Through a Nurse’s Eyes

A short film offering a firsthand perspective of the brutality of the pandemic inside a covid-19 i.c.u..

I was looking through the window of a Covid I.C.U. And that’s when I realized I might see someone die. I didn’t even know who she was. But I was filled with immense grief as she edged closer to death by the hour. What I didn’t know yet was that by the time I left just two days later, at least three patients would be dead. The vaccine offers hope, but the sad truth is that the virus continues its brutal slaughter in I.C.U.s like this one in Phoenix, Ariz. The only people allowed in are health care workers. They’re overworked and underpaid in a deluged hospital. I wanted to know what it is like for them now, after a year of witnessing so much death. Eager to show us their daily reality, two nurses wore cameras so that for the first time we could see the I.C.U. through their eyes. “Unless you’re actually in there, you have no idea. Nobody can ever even imagine what goes on in there.” [MUSIC PLAYING] This I.C.U. contains 11 of the hospital’s sickest Covid patients. Most of them are in their 40s and 50s. And they are all on death’s door. It’s an incredibly depressing place. I blurred the patients faces to protect their privacy. But I also worried that blurring would rob them of their humanity. The family of this patient, the one who is rapidly declining, allowed her face to be shown. And they readily told me about her. Her name is Ana Maria Aragon. She’s a school administrator and a 65-year-old grandmother. Sara Reynolds, the nurse in charge of this I.C.U., organized a video call with Ana’s family to give them a chance to be with her just in case she didn’t make it. “It just breaks my heart when I hear families saying goodbye.” You might expect the doctors to be running the show. But it is really the nurses who are providing the vast majority of the care. “We do everything. We give them baths every night.” “Rubbing lotion on their feet.” “Shave the guys’ faces.” “Cleaning somebody up that had a bowel movement. It doesn’t even register as something gross.” “Look, I walk into the room. I say, hey, sounds like you have Covid. And I might order a chest X-ray. I might order blood work. I might order catheters. All that stuff is done by the nurse. I may have spent 10 minutes. The nurse might spend seven or eight hours actually in the room, caring for them. Let’s say there was a day that nurses didn’t come to the hospital. It’s like, why are you even opening?” “Ibuprofen.” 12-hour-plus shifts, isolated in this windowless room, these nurses survive by taking care of each other. “Aww, thank you.” And by finding small doses of levity. [MUSIC - JAMES BAY, “LET IT GO”] “(SINGING) Wrong. Breeze.” “I’m getting older now, and there’s all these new young nurses coming out. And I feel like a mom to all of them. Morgan, she’s got big aspirations. She loves to snowboard, and she’s so smart. And Deb, Deb’s just— she’s funny.” “I tease her all the time. I can tell her to do anything, and she’ll just do it because I think she’s scared of me because I just always say, make sure you have no wrinkles in those sheets.” The patients spend most of their time on their stomachs because it makes it easier to breathe. But the nurses have to turn them often to prevent pressure sores. There was one woman in her 50s who was so critical that this simple procedure risked killing her. “Even just turning them on their side, their blood pressure will drop. Their oxygen levels will drop.” “Her heart had actually stopped the day before. And so the concern was if it was going to make her heart stop again.” “Then come over. Push.” “We were all watching the monitors.” “I felt relieved like, whew, we did it.” Arizona’s a notoriously anti-mask state. And it faced a huge post-holiday surge in Covid cases. In January, the month I was there, Arizona had the highest rate of Covid in the world. As a result, I.C.U.s like this one have too many patients and not enough nurses. “Because they’re so critical, they need continuous monitoring, sometimes just one nurse to one patient with normally what we have is two patients to one nurse. But there definitely are times when we’re super stretched and have to have a three-to-one assignment.” A nurse shortage has plagued hospitals over the past year. To help, traveler nurses have had to fly into hotspots. Others have been forced out of retirement. Especially strained are poorer hospitals like Valleywise, which serves a low-income, predominantly Latino community. “Many of our patients are uninsured. Some of them have Medicaid, which pays something but unfortunately not enough.” This means they simply can’t compete with wealthier hospitals for nurses. “There is a bidding war. The average nurse here, give or take, makes about $35 an hour. Other hospitals, a short mile or two away, might pay them $100.” “We lost a lot of staff because they took the travel contracts. How can you blame them? It’s sometimes a once-in-a-lifetime opportunity to make a lot of money.” “Every single day I’m off, I get a call or a text. ‘Hey, we desperately need help. We need nurses. Can you come in?’” This nursing shortage isn’t just about numbers. “Physically it’s exhausting. We’re just running. We don’t have time to eat or drink or use the restroom.” “They have kids at home, doing online school. And I think, gosh, they haven’t even been able to check on their kids to see how they’re doing.” “My days off, I spend sleeping half the day because you’re exhausted. And eating because we don’t get to eat here often.” Nurses have been proud to be ranked the most trusted profession in America for nearly two decades. But during Covid, many worry they aren’t able to uphold the standards that earned them such respect. “I can’t give the quality of care that I normally would give.” “It’s absolutely dangerous.” “That’s demoralizing because we care. We’re nurses. It’s our DNA.” Ana had been in the hospital for over a month. Her family told me she was born in Mexico. She came to the States 34 years ago, first working in the fields before eventually landing her dream job in education. She’s beloved at her school. Former students often stop her in town and excitedly shout, Miss Anita. She was very cautious about Covid. She demanded her family always wear a mask and yelled at them to stay home. Yet, tragically, she somehow still caught it. “She had been declining over the course of several days. It’s a picture we have seen far too often that we know, this one is going to be coming soon.” Because there is no cure for Covid, the staff can only do so much. Once all the ventilator settings and the medications are maxed out, keeping a patient alive will only do more harm than good. So Ana’s family was forced to make a tough decision. “And I talked to family and let them know that we have offered her, we have given, we have done everything that we can, there’s nothing more that we can do. The family made the decision to move to comfort care.” “If I’m there while someone’s passing, I always hold their hand. I don’t want somebody to die alone. That’s something that brings me peace.” “Thank you.” “Thank you.” “Dance floor is packed. People hugging, holding hands, and almost no one wearing a face mask.” “I think like many health care workers, I’m angry a lot. And my faith in humanity has dwindled.” “How can you think this isn’t a real thing? How can you think that it’s not a big deal?” “Free your face. Free your face.” Arizona Gov. Doug Ducey has advocated for personal responsibility over mask mandates even though he’s been photographed maskless at a gathering and his son posted a video of a crowded dance party. “Even on the outside, they go, I don’t care. I’m not wearing a mask. I’m not getting the vaccine. That’s bullshit. The second they come into the hospital, they want to be saved. Never do they say, ‘I made the decision. I’m accepting this. Don’t do anything, doctor.’” Half a million people in this country have died from Covid. Many have been in I.C.U.s with nurses, not family members holding patients’ hands. “I always wonder, are they still going to be there when I get to work? It’s on my mind when I get home. Are they going to make it through the night? There’s one that I can think of right now.” One patient in his late 50s was so critical that he required constant supervision. Each of his breaths looked painful. “There was one day that he was kind of— he was looking a little bit better. And so he was able to shake his head and smile. And we set up a video call for him. And it was just the sweetest thing ever. I could hear his little grandson— he was probably 4 years old or so. And I saw him on the screen, too. And he was just jumping up and down, so excited. ‘You’re doing it, Grandpa. You’re doing it. We love you. Look at you. You’re getting better.’ It just broke my heart. It broke my heart. He’s one that I don’t think is going to be there when I get back on Sunday.” But I’d already been told something Sara hadn’t. The patient’s family had decided to take him off life support. “Yesterday they did? Oh. And I just think of his little grandson. And ‘you’re doing it, Grandpa. You’re doing it.’” He wasn’t the only patient who didn’t make it. When I went back to the hospital, I noticed that the bed of the patient I’d seen get flipped over was empty. My heart sank. I knew this meant she’d passed away. “What’s sad is when I go back, those beds will be full. They’ll have somebody else there just as sick with another long stretch of a few weeks ahead of them before it’s time for their family to make that decision.” I’d never before seen someone die. And even though I didn’t know these people, witnessing their deaths left me sleepless, exhausted, and depressed. It’s unfathomable to me that these nurses have gone through that every single week, sometimes every single day for an entire year. I assumed the nurses must block out all the deaths to be able to keep going, but they don’t. They grieve every single one. “I’ve always loved being a nurse. It’s what I’ve always wanted to do. And these last couple months, it’s definitely made me question my career choice.” And what makes their situation so tragic is that many of these nurses hide their trauma, leaving them feeling isolated and alone. “We’re the only ones that know what we’re going through. I don’t really want to tell my family about everything because I don’t want them to feel the same emotions that I feel. I don’t want them to know that I carry that burden when it— that it is a lot. I’m Mom. I’m strong. I can do anything. And I don’t want them to see that.” Leadership in the pandemic hasn’t come from elected officials or spiritual guides but from a group that is underpaid, overworked and considered secondary, even in their own workplaces. As so many others have dropped the ball, nurses have worked tirelessly out of the spotlight to save lives, often showing more concern for their patients than for themselves. I worry their trauma will persist long after we re-emerge from hibernation. Covid’s legacy will include a mass PTSD on a scale not felt since World War II. This burden should not be ignored. “Thank you. Thank you. I feel, yeah. And you’re all amazing.” [MUSIC PLAYING]

Nevertheless, we find ourselves too often with a shortage of nursing care. Many decades of research reveal two major reasons: First, poor working conditions, including not enough permanent employer-funded positions for nurses in hospitals, nursing homes and schools. And second, the failure of states to enact policies that establish and enforce safe nurse staffing; enable nurses to practice where they are needed, which is often across state borders; and modernize nurse licensing rules so that nurses can use their full education and expertise.

Training more nurses cannot solve these problems. But more responsible management practices in health care, along with better state policies, could.

Not only are states not requiring safe nurse staffing, but individuals also do not have the information and tools they need to pick hospitals and nursing homes based on nurse staffing or to advocate better staffing at their hospitals and nursing homes.

Ninety percent of the public in a recent Harris Poll agreed that hospitals and nursing homes should be required to meet safe nurse staffing standards. But powerful industry stakeholders — such as hospital and nursing home organizations and, often, medical societies — are strongly opposed and usually defeat legislation.

The New York State Legislature is the first in the postpandemic era to fail to approve proposed safe nurse staffing standards for hospitals. The legislature passed a bill that did not require safe nursing ratios, opting instead for internal committees at hospitals to oversee nursing and patient safety. This happened despite compelling evidence that the legislation would have resulted in more than 4,370 fewer deaths and saved more than $720 million over a two-year study period through shorter hospital stays.

What are the solutions? While there are some actions the federal government could take, the states have most of the power because of their licensing authority over occupations and facilities. The hospital and nursing home industries have long failed to police their members to remove the risk of nurse understaffing. So states should set meaningful safe nurse staffing standards, following the example of California, where hospital nurses cannot care for more than five adult patients at a time outside of intensive care. State policies are tremendously influential in health care delivery and deserve greater public attention and advocacy, as they are also ripe for exploitation by special interests.

In states with restrictive nurse licensing rules, many governors used their emergency powers during Covid surges to waive restrictions. If they were not needed during a national medical emergency, why are they needed at all?

Still, the federal government has a role to play: It should require hospitals to report patient-to-nurse staffing ratios on the Medicare Hospital Compare website, because transparency motivates improvement. The federal government could incentivize the states to pass model nurse practice acts.

We need influential champions taking on special interests so that states will make policy changes that are in the public’s interest. AARP is using its clout to advocate nurse-friendly policies. But health insurers and companies such as CVS, Walgreens and Walmart that provide health care have been on the sidelines.

While we long to go back to pre-Covid life, returning to chronic nurse understaffing in hospitals, nursing homes and schools would be a big mistake. We owe nurses and ourselves better health care resources. The so-called nurse shortage has become an excuse for not doing more to make health care safe, effective and patient-centered. State legislators must do their job. Health care leaders must fund enough positions for nurses and create reasonable working conditions so that nurses will be there to care for us all.

Linda H. Aiken is a professor of nursing and sociology and the founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

Follow The New York Times Opinion section on Facebook , Twitter (@NYTopinion) and Instagram .

An earlier version of this article misstated the status of legislation on nurse staffing standards in New York State. The bill passed without setting minimum nursing ratios; it did not fail to pass.

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Nursing Homes In The US Argumentative Essay Samples

Type of paper: Argumentative Essay

Topic: Elderly , Health , Home , Medicine , Services papers , Nursing , Family , Love

Words: 2500

Published: 03/16/2020

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Employing the services of Nursing Homes is becoming a huge trend in the United States in recent years. Families can bring their elderly and ailing love ones to these nursing homes and pay for a certain cost to support their treatment. However, there is a growing debate within the country with regards to the use of these nursing homes as some groups believe families should take care of their love ones at home. Supporters to these alternative facilities argue that nursing homes would provide better care to their love ones, especially given the financial and living conditions. This paper will discuss the arguments surrounding the use of nursing home for love ones and answer as to why placing them to these homes would be beneficial or disadvantageous for the families thinking of using the service.

Placing Love Ones in Nursing Homes

When a person reaches the age of 70, family members would start clamoring for ideas as to what would be done in order to take care of their elderly family member. Some families opt to consider assigning someone to take care of their love ones at home due to the strict schedules of people today. Others would take care of their love ones by themselves due to the sentiment that it is the child’s responsibility to give back to their love ones. However, in recent years, there is a growing interest in many families to seek the assistance of nursing homes in order to take care of these elderly or ailing family members. Positions have greatly varied within the public regarding the presence of these nursing homes. Some argue that these nursing homes should not be trusted, while a few welcome its use. Families should place their love ones in nursing homes because these love ones would be taken care well by these nursing homes as they specialize in taking care of the specialized needs of these elderly and ailing family members despite the costs it entails. The exact definition of nursing homes have varied throughout the years given the lack of terminology for these services in the early years. However, according to Giacalone (2001), the National Center for Health Statistics (NCHS) defined nursing homes as “facilities with three or more beds that is either licensed as a nursing home by the state, certified as a nursing facility under Medicare or Medicaid, identified as a nursing unit in a retirement center, or determined to provide nursing or medical care”. Some institutions also call these facilities as extended care facilities, intermediate care facilities for the mentally retarded and SNFs. Nursing homes often have state-of-the-art medical facilities and medical staff that can be called to duty 24/7. Before nursing homes can operate in the United States, they would have to apply for state licenses and adhere to reimbursement regulations, classification and termination policies. Most of these policies vary per state and some states would require separate licenses for nursing homes that have separate operations on all-day care facilities or medical accreditation . Purdy (2013) stated that nursing homes became known in the US since the 1930 when many American families brought their ailing family members to “poor houses.” Many criticized these poor houses due to their deplorable living conditions and health care. In 1935, the Congress passed the Social Security Act which was included in the New Deal program to support its aging population. Federal grants were given per state in order to improve health care, as well as the creation of nursing homes for the elderly and ailing. By the 1950s, nursing homes were licensed and at the same time, criticized for their operations. From the 50s to the 80s, exploitation was prominent in the industry and misled many Americans in the process. The government immediately responded in 1965 by passing the Older Americans Act and the Title III grants which would establish the community program for the elderly which would cater not just for their medical needs but also for their maintenance. Studies were also supportive over the initiative of the government and aided in the establishment of the Nursing Home Reform Act of 1987, which would regulate Medicare and Medicaid in providing financial assistance to nursing homes. The Act also added the necessary requirements for nursing home licensing. Since the growth of these nursing homes throughout the country, there are several sentiments that have been raised with regards to leaving loved ones in these nursing homes. Opponents cited three major arguments against nursing homes: cost and quality, reduction of self-reliance and independence and the trauma it entails to the loved ones. In terms of costs, it is reported by Ellis (2013) that nursing home services now costs up to $80,000 a year in comparison to its $67,527 five years ago. According to the Genworth 2013 Cost of Care Survey, factors such as insurance, food, maintenance and labor have triggered the increase of nursing home costs. As a result of these higher costs, a simple semi-private room nowadays now rate up to $75,405, 23% higher than it was five years ago. With these high fees, people tend to prefer using assistive living facilities that cost only up to $41,400. Others also prefer at-home care because it is cheaper to do these treatments at home, and they would also find it cheaper to pay for food and services . Hand in hand with the high costs is the quality of care these nursing homes can provide to family’s loved ones. Pesis-Katz, Phelps, Temkin-Greener, Spector, Veazie, and Mukamel (2013) stated that consumers are often misled by the high hotel-like quality of nursing homes around the country due to the misleading and inaccurate information available. Some of the information available for prospect residents come from the internet and sometimes, it is not easy to understand. Since customers cannot interpret and understand the information with regards to the quality of health care, they often prefer to select nursing homes with high grade hotel type service. They often use indirect methods to observe if the nursing home is good for their love ones. Some factors they take into consideration are nonprofit ownership and the number of occupancy, seeing it as a sign for high quality for its service and capability. As a result of the inconsistency of information, it is likely that the service they would get would not be suitable for their love ones . Loved ones who are placed in these nursing homes also feel the reduction of self-reliance and independence. According to the Illinois Council on Long Term Care (n.d.), any person who is admitted to nursing homes would lose their privileges to keep their apartments and homes. Most of their possessions would also be sold or given to charity, removing the possibility for the person to give the possessions as an inheritance to their children or grandchildren. Nursing homes only allow just a few possessions for these loved ones to hold; however, they would have to fit it on a small space that sometimes, they share with another person. Aside from losing their homes, loved ones admitted to nursing homes would also cause a loss of status, finances and relationships that may affect the loved one’s confidence and independence. Residents are also restricted from their movements considering that every activity is now timed by the institution and where the resident would need to stay. Finally, there are also implications to loved ones when they are placed in nursing homes, mostly changing their attitudes and development of trauma. Many would become angry for being placed in a nursing home especially with the loss of their possessions and rights. Some elderly often get angry because of the restrictions placed on their movements while in these institutions. As a result of their anger, they would become trouble-makers in the nursing home and it may hinder their recovery. Some, especially those who lose their love ones prior to their admission to these institutions, would feel bouts of depression or even regression. These residents would become overly dependent towards their caretakers or their love ones. There are also bouts of denial for these residents as they would feel that their condition or placement in the nursing home is not true. They believe that they would be removed from these centers soon and go home afterwards . However, while there are people against the use of nursing homes in the country, many Americans today prefer to use nursing homes due to the benefits it has for both the family and the love one that would be enrolled in this service. Many often prefer sending their loved ones on these nursing homes due to the all-round care provided by these facilities. According to the report by Sun Advocate (2008) and EHealthMedicare (n.d.), many of America’s nursing homes have available professionals to cater to emergencies and immediate medical support 24 hours a day. While doctors may not always be available in the early hours of the day, nurses are trained to take care of their patients and do rounds regularly. If these love ones were taken care of at home, their family members would not be able to cater to the exact need of the ailing or elderly loved one. The family would have to adopt with the schedule of the elder, which may prevent them from going to their own duties on time. With nursing homes available, families can visit their family members on free days and be assured that their love ones are treated and monitored regularly. In addition, these professionals and personnel can also provide specialized treatment necessary to improve the health and well-being of the citizen. Nursing homes have custodial care, which aids in preparing meals, bathing and dressing for their residences. The skilled nursing care unite is where the nurses and rehabilitation specialist would determine what type of care or treatment would be done. This type of care would include activities such as medication management, wound care and specialized functions depending on the availability of medical equipment in the facility. Some facilities also offer rehabilitation services, especially for patients which have been placed under surgery and other strenuous activity. The doctor of the resident would be able to determine as to how long rehabilitation would occur. Finally, nursing homes are also well known for their long-term care facilities to aid patients with major diseases. Prescription drugs and medical supplies are also readily available for use by these workers to ensure continuous service and treatment for residents. Nursing homes also allow their love ones to meet up new friends and acquaintances as nursing homes are like small communities. In at-home treatments and care, the elderly or ailing family member would only have limited contact with their peers. However, in nursing homes, they are able to be with their age group and even go on regular social gatherings and celebrations: may it be visits to museums or simple group meals in the nursing home. In some instances, nursing homes actually incite socialization given that the nursing home acts as a special home for its patients and residents. They can use the open kitchens and public areas to meet up with their fellow residents. Nursing homes also may have sectors catering for other in-need residents, who are not necessarily elderly. They may also find certain nursing homes that would permit couples in staying together to provide a good environment for their development and recovery. Nursing homes are also quite safe and promises to provide excellent service as these nursing homes are regularly checked by the United States government for their capacity and services. Medicare and Medicaid also provide regular reviews to the public in order to determine which nursing homes adhere to their policies. Evaluations are done regularly to ensure that quality is not compromised and it is expected that nursing homes update their programs to stay up-to-date to the new improvements in healthcare . Nursing homes also make sure that patients do not endanger themselves further especially with the onset of very complicated diseases like dementia and Alzheimer’s . Family must always be cherished no matter what one feels about each family member. As these family members get older, it is crucial that they are given all the love and care possible to make their lives comfortable in their final years. However, taking care of these ailing and elderly family members can be very difficult especially due to the medical and financial needs of these loved ones. With the introduction of nursing homes, families now have a choice to use these services to take care of their love ones. On the one hand, these nursing homes can be quite costly each year and it is a question as to whether or not the service matches the cost. These nursing homes can even make the situation of the elderly and ailing family members to worsen due to the impact of their residencies. On the other hand, using nursing homes not only benefits the family member but also the family in general. The family member would greatly benefit due to the ready access to health care, while family members would be relieved with the financial burden attached with taking care of these love ones.

Centers for Disease Control and Prevention. (2014, May 14). Nursing Home Care. Retrieved from CDC FastStats: http://www.cdc.gov/nchs/fastats/nursing-home-care.htm EHealth Medicare. (n.d.). Nursing Homes and Medicare. Retrieved from EHealthMedicare: http://www.ehealthmedicare.com/about-medicare/nursing-homes/ Ellis, B. (2013, April 9). Nursing home costs top $80,000. Retrieved from CNN Money: http://money.cnn.com/2013/04/09/retirement/nursing-home-costs/ Giacalone, J. (2001). The U.S. Nursing Home Industry. New York: M.E. Sharpe. Illinois Council on Long Term Care. (n.d.). Understanding the Transition to Life in a Nursing Home. Retrieved from Family Resource Center: http://nursinghome.org/fam/fam_004.html Pesis-Katz, I., Phelps, C. E., Temkin-Greener, H., Spector, W. D., Veazie, P., & Mukamel, D. B. (2013). Making Difficult Decisions: The Role of Quality of Care in Choosing a Nursing Home. American Journal of Public Health, 103(5). Purdy, E. (2013). Nursing homes. Ipswich: Salem Press. Sun Advocate. (2009, April 10). Advantages and disadvantages of nursing home care for the elderly. Retrieved from Sun Advocate: http://www.sunad.com/index.php?tier=1&article_id=12944

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Understanding the Differences Between Nursing Homes and Assisted Living

Learn about the key differences between nursing homes and assisted living communities to determine which is the best option for your loved one.

This article is based on reporting that features expert sources.

Nursing Homes vs. Assisted Living

Key Takeaways:

• Assisted living and nursing care are two different care levels.
• Assisted living is designed for seniors who are able to maintain some level of independence but need help with daily tasks, such as bathing, grooming and dressing.
• Nursing home care, on the other hand, is for two other groups of seniors: those who cannot live alone and need round-the-clock care for chronic conditions, and those requiring short-term care after a hospital stay.

There's an ever-growing need for senior care options. Across the country, 70% of those currently age 65 or older will need some kind of long-term service or support during the remainder of their lifetime, according to a U.S. Department of Health and Human Services report .

Getty Images

But the unique care needs of your elderly loved one won't fit neatly into a box. Your dad might have trouble remembering to take his medications, but he has no issues using the restroom. A recent shoulder injury might make it taxing for him to get dressed and perform daily hygiene, but he's able to move around with his walker just fine.

When comparing these diverse needs to the available options for senior care, it can be hard to parse the differences among facilities, including the levels of care provided.

“The lines are hazy. You often find residents in assisted living that should be in a nursing home, and vice versa. If Mom and Dad require a nurse more times than not, use that as a benchmark to consider a nursing home," advises Anthony Cirillo, a North Carolina-based health, aging and caregiving expert and president of The Aging Experience, a company that provides consulting, keynote speaking and products for the senior living industry and older adults. "Don't bear the burden yourself."

In this article, we outline key aspects of assisted living communities and nursing homes to help you better understand which one may be the best fit.

What Are Assisted Living Facilities ?

Assisted living is a long-term care option for seniors who may need some assistance with activities of daily living , such as bathing, dressing or grooming, or with daily nonmedical needs, including:

• Day-to-day housekeeping duties and chores
• Social enrichment activities
• Medication management
• Transportation to  medical appointments  or stores

Assisted living residents have to meet certain standards to live there to ensure they don't exceed the amount of care the community can provide.

Assisted living communities in New York, for example, require residents to be able to walk 150 feet on their own or with mobility equipment.

"If the person cannot meet these standards, then they are more likely going to be placed in a nursing home," says Roxanne Sorensen, an aging life care specialist and owner of Elder Care Solutions of WNY in Buffalo, New York.

Assisted living communities may also have the following features:

• Separated apartments , though some may require residents to share a room with one companion
• Access to common areas, like dining areas, living spaces and activity centers
• Gardens or outdoor walking areas
• Three meals a day
• 24-hour supervision
• Housekeeping
• On-site social events
• Accommodations for pets

Touring a few assisted living communities will give you an idea of which amenities are offered in your area and how much they may cost.

In addition, assisted living facilities may offer secured sections of the building to care for residents with memory loss. These residential settings tend to be much more attractive than the traditional nursing homes that care for those with Alzheimer’s disease and other forms of dementia.

Find assisted living near you

Search by state, city or ZIP code to find the best facility for you.

When comparing assisted living options with nursing homes, nursing homes accommodate residents with more advanced care needs.

These residents often have chronic conditions or a lack of mobility, and the services available at these facilities can help residents keep their health stable. Because residents may struggle with health issues and cannot live alone, a move to a nursing home is usually more permanent. These moves are also typically family decisions.

Nursing care facilities offer:

• A higher level of daily physical care, security and supervision than assisted living
• More staff support than assisted living, especially nurses and nursing assistants
• Increased ability to offer skilled nursing tasks, like managing wounds, catheters or IV lines
• A mix of care levels, from short-term post-hospital stays to long-term custodial care and skilled nursing needs

Some elderly adults may just need a short-term stay after a hospital discharge. For example, after having a stroke , some seniors may need a few days of intensive therapy but then are safe to go back to independent living. In these cases, many nursing homes or skilled nursing facilities accommodate these short-term skilled nursing stays. Frequently, moves to an SNF are after a hospital discharge and recommended by a physician.

Differences Between Assisted Living and Nursing Homes

The differences between assisted living and nursing homes will vary depending on each individual community.

Seven key differences between assisted living and nursing homes may include:

1. Level of medical staff and security

Nursing homes offer a higher level of care, so more nurses, therapists and specialists will be on the premises. Physicians might also round more often than they would at an assisted living community.

Both types of care homes for the elderly charge a monthly fee.

However, many facilities are moving away from the traditional flat rate.

"They are moving toward a fee-for-service structure," Sorensen says. "It makes it difficult for families to plan financially as you can’t predict what level of care your loved one will be in two years."

Due to nursing home residents requiring more extensive care, the cost of nursing homes is usually higher and can be expensive.

"I have found over the last 10 to 20 years that fewer people are able to afford that level of care," says Howard S. Krooks, an elder law attorney practicing in Florida, New York and Pennsylvania with Cozen O'Connor.

According to Genworth Financial's 2023 Cost of Care survey, the average monthly cost for an assisted living community is $5,350. A private room in a nursing home averages $9,733 per month.

3. Insurance coverage

Medicare will pay for certain types of short-term nursing care, like rehabilitation after a knee replacement . But Medicare does not cover long-term nursing home or assisted living care.

Medicaid covers nursing home care, but it may only cover assisted living services depending on facility policies and the state residents are living in. Because Medicaid is a joint federal and state public health insurance program administered by individual states, coverage for assisted living services varies.

4. Social atmosphere

All senior care homes will have some type of social scene. However, as assisted living residents require less direct care than nursing homes, the social atmosphere is often elevated. Activities , such as senior fitness or music classes, are geared toward individuals who are able to move around on their own and communicate.

5. Spatial layout

Assisted living communities may have more common areas and room for their residents to walk around. There are often more private rooms or suites, whereas nursing homes may have smaller and shared rooms.

6. Federal regulations

Nursing homes are subject to more government oversight by both the state and federal governments to ensure quality . The federal Centers for Medicare and Medicaid Services oversees nursing homes. Assisted living communities are subject to state regulations.

To compare the quality of nursing homes, you can visit Medicare Nursing Home Compare , which CMS runs.

You can also look at U.S. News' Best Nursing Homes ratings. For 2024, U.S. News evaluated more than 15,000 nursing homes on a variety of indicators of quality.

Find nursing homes near you

Search by state, city or ZIP code to find the best residence for you.

7. Independence offered to residents

Assisted living communities allow their residents more independence than nursing homes. Because assisted living residents don't have as many medical conditions, they will have more freedom to leave the facility to go to community events or visit with family outside the premises. Nursing home residents are also allowed to leave, but they may require more assistance and planning to do so.

Similarities Between Nursing Homes and Assisted Living

Despite having some differences, there are a few key similarities between assisted living and nursing homes.

Three similarities between nursing homes and assisted living include:

1. Use of the same building

A facility may refer to its senior care home as a nursing home, but it may offer various levels of care. They could have a mix of nursing home care, assisted living or even memory care offered in the same location.

"Each facility chooses which areas to add to their building, such as a one-person assist area, two-person assist area and so on," Sorensen says. "Each building is different."

2. Round-the-clock on-site medical staff

Unlike independent senior living communities, nursing homes and assisted living communities will each have medical staff on-site at all times.

3. Availability of community areas

Even nursing care facilities with residents who require a lot of care will have common areas for them to dine, visit with family or even just to offer a change of scenery. This differs from a hospital, where patients typically cannot access spaces outside their rooms.

Assisted Living vs. Nursing Home: Which Is the Best Fit?

Choosing nursing homes versus assisted living can feel daunting.

Here are a few circumstances to keep in mind:

• Do you anticipate your or your loved one's care needs will change quickly? If that's the case, you may want to choose a facility that offers both nursing home care and assisted living.
• What do medical providers have to say? A medical provider can perform something called a functional assessment, which helps determine how much care your loved one needs. They'll also have insight regarding any chronic conditions, like how quickly they see your loved one's chronic kidney disease progressing, for example.
• How much medical care do you need? If you only need help with a few daily activities, like getting out of bed in the morning and having your food prepared for you, assisted living is a viable option.

Other questions you may have could include:

• Is assisted living better than a nursing home?  Neither is a better option than the other. It depends on individual needs. A nursing home may be a poor choice for someone looking for lots of social activities and who doesn't need a lot of medical interventions. However, assisted living may not be a fit for someone who needs extensive help caring for themselves.
• Who is the best fit for assisted living?  Assisted living is the best fit for someone who can communicate on their own. They also should be able to do most of their daily care independently, like brushing their teeth or changing their clothes. It's OK if they need some help with specific tasks, like a steadying hand to help them move from bed to wheelchair, or if they have a minor injury or condition that prevents them from being fully independent. Most assisted living communities automatically include some activities of daily living in their basic plan, then charge more for others, like laundry or medication management.
• Who is the best fit for a nursing home?  A nursing home is the  best fit  for someone who needs moderate to extensive care to perform their daily activities. They may also require skilled nursing tasks, like wound care, catheter care or IV medications.

Overall, the decision of choosing between assisted living and nursing homes should be made with the senior , their family and their medical team.

Bottom Line

In summary, nursing homes and assisted living care may take place in the same building sometimes, but they are not the same level of care .

Nursing home care is for those who need more daily care and assistance. Assisted living is a more independent type of senior living, but it still offers some medical oversight.

Enlist the help of a professional, such as a geriatric physician or a geriatric care manager , to guide you in making an informed decision on how to choose assisted living versus a nursing home. Medical professionals can assess the needs of each potential resident using a scale to measure the activities of daily living. The more assistance needed, the higher the level of care – and cost – required.

Pros and Cons of Assisted Living

The U.S. News Health team delivers accurate information about health, nutrition and fitness, as well as in-depth medical condition guides. All of our stories rely on multiple, independent sources and experts in the field, such as medical doctors and licensed nutritionists. To learn more about how we keep our content accurate and trustworthy, read our  editorial guidelines .

Cirillo is a North Carolina-based health, aging and caregiving expert and president of The Aging Experience, a company that provides consulting, keynote speaking and products for the senior living industry and older adults.

Krooks is an elder law and estate planning attorney with Am Law 100 Firm Cozen O’Connor. He practices in Florida, New York and Pennsylvania. He has served as chair of the Florida Bar Elder Law Section, president of the National Academy of Elder Law Attorneys and chair of the New York State Bar Association Elder Law Section.

Sorensen is an aging life care specialist and owner of Elder Care Solutions of WNY, a care management consultancy in Buffalo, New York.

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Home — Essay Samples — Nursing & Health — Medicare — The Benefits of Nursing Homes

The Benefits of Nursing Homes

• Categories: Medicare

About this sample

Words: 498 |

Published: Jul 17, 2018

Words: 498 | Page: 1 | 3 min read

Works Cited

• Johnson, R. W., & Wiener, J. M. (2006). A Profile of Frail Older Americans and Their Caregivers. The Urban Institute.
• Bullock, K., & Hamblin, A. (2008). The Development of Community-Based Services for Older People: A Focus on Home Care. The British Journal of Social Work, 38(3), 541-558.
• Kane, R. A., & Kane, R. L. (2000). Assessing Older Persons: Measures, Meaning, and Practical Applications. Oxford University Press.
• Gitlin, L. N., Winter, L., Dennis, M. P., Hodgson, N., & Hauck, W. W. (2010). Targeting and Managing Behavioral Symptoms in Individuals With Dementia: A Randomized Trial of a Nonpharmacological Intervention. Journal of the American Geriatrics Society, 58(8), 1465-1474.
• Gaugler, J. E., Mittelman, M. S., Hepburn, K., Newcomer, R., & Dorn, K. (2010). Effects of Dementia Caregiving on Caregiver Depressive Symptoms, Social Support, and Health: A Longitudinal Analysis. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 65B(6), 788-798.
• Home Care Assistance. (n.d.). In-Home Care for Seniors with Cognitive Decline. Retrieved from https://homecareassistance.com/cognitive-therapeutics-methods
• Verghese, J., Lipton, R. B., Katz, M. J., Hall, C. B., Derby, C. A., Kuslansky, G., ... & Buschke, H. (2003). Leisure Activities and the Risk of Dementia in the Elderly. The New England Journal of Medicine, 348(25), 2508-2516.
• Schulz, R., & Sherwood, P. R. (2008). Physical and Mental Health Effects of Family Caregiving. The American Journal of Nursing, 108(9 Suppl), 23-27.
• National Institute on Aging. (2021). Alzheimer's Caregiving Tips: Home Safety. Retrieved from https://www.nia.nih.gov/health/alzheimers-caregiving-tips-home-safety
• Brodaty, H., & Donkin, M. (2009). Family Caregivers of People with Dementia. Dialogues in Clinical Neuroscience, 11(2), 217-228.

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Appropriate leadership in nursing home care: a narrative review

Nick zonneveld.

1 Tilburg University, TIAS School for Business and Society, Tilburg, The Netherlands, and Vilans, National Centre of Expertise in Long Term Care, Utrecht, The Netherlands

Carina Pittens

2 Vrije Universiteit, Athena Institute, Amsterdam, The Netherlands

Mirella Minkman

3 Tilburg University, TIAS School for Business and Society, Tilburg, The Netherlands, and Vilans, National Centre of Expertise in Long Term Care, Utrecht, The Netherlands

The purpose of this paper is to synthesize the existing evidence on leadership that best matches nursing home care, with a focus on behaviors, effects and influencing factors.

Design/methodology/approach

A narrative review was performed in three steps: the establishment of scope, systematic search in five databases and assessment and analysis of the literature identified.

A total of 44 articles were included in the review. The results of the study imply that a stronger focus on leadership behaviors related to the specific context rather than leadership styles could be of added value in nursing home care.

Research limitations/implications

Only articles applicable to nursing home care were included. The definition of “nursing home care” may differ between countries. This study only focused on the academic literature. Future research should focus on strategies and methods for the translation of leadership into behavior in practice.

Practical implications

A broader and more conceptual perspective on leadership in nursing homes – in which leadership is seen as an attribute of all employees and enacted in multiple layers of the organization – could support leadership practice.

Originality/value

Leadership is considered an important element in the delivery of good quality nursing home care. This study provides insight into leadership behaviors and influencing contextual factors specifically in nursing homes.

1. Background

Leadership is seen as essential for the creation of cultural and structural change within organizations and the delivery of good quality nursing home care ( Anderson et al. , 2005 ; Martin and Learmonth, 2012 ). Various studies confirm that leadership affects e.g. business management, information flows, health-related quality indicators, long-term vision, organizational structure, organizational culture, work environment and quality of care in nursing homes ( Anderson et al. , 2005 ; Castle and Decker, 2011 ; Cummings et al. , 2010 ; Jeon et al. , 2015 ). Therefore, more insight is needed into how leadership should look to contribute to organizational and cultural change in nursing home care.

Leadership can be defined as “a process whereby individual influences a group of individuals to achieve a common goal” ( Hunt, 2004 , p. 3). Based on a review of leadership literature, Hunt (2004) distinguishes four common features of leadership. Leadership: is a process, involves influence, occurs in a group context and involves goal attainment. Leadership theory still divides leadership styles into two main groups: relationship-oriented leadership styles and task-oriented leadership styles. While relationship-oriented leadership focuses on individual persons and relationships, task-oriented leadership aims at the accomplishment of tasks. This division could also be interpreted as transformational leadership and transactional leadership ( Avolio et al. , 1999 ). Transformational leadership is reflected in a process, in which a leader connects with his/her followers, with the aim of increasing intrinsic motivation to enhance performance. The driving force is a shared vision. Transactional leadership is a more top-down style, focusing on transactions between the leader and followers. There are clear structures, rules and procedures and the extrinsic motivation of employees is addressed ( Avolio et al. , 1999 ). An example of transactional leadership is giving a personal reward for employees that achieve a certain goal, like a financial bonus. In our study, the two main streams of transformational and transactional leadership are used as an ordering framework, supplemented with a contingency approach category: context-dependent leadership styles. These styles assume that there is no universal leadership style and that different contexts and circumstances require different leadership styles ( Northouse, 2018 ).

Various publications have been written about leadership in nursing home care. In most of these studies relational and transformative-related leadership styles are considered to be most appropriate in a nursing home and aged care ( Anderson et al. , 2005 ; Corazzini et al. , 2015 ; Jeon et al. , 2015 ). The focus of most studies is the relationship between particular leadership styles and desired outcomes rather than understanding the behaviors and context behind them. However, as leadership is a process that takes place between people ( Hunt, 2004 ), it consists of many components and influencing factors. It could also take place at multiple places in an organization, both formally and informally. The relationship between how leadership is executed and the outcomes achieved are, therefore, not simple or linear ( Northouse, 2018 ). Therefore, more in-depth knowledge is required regarding leadership behaviors, the effects and the factors influencing them.

This study aims to provide a deeper understanding of what leadership is appropriate in nursing home care, also considering the changing context. To this end, various leadership behaviors, their effects and their influencing factors are examined by performing a narrative literature review with a systematic search.

The objective of this study is to synthesize the existing evidence on leadership that best matches nursing home care, with a focus on behaviors, effects and influencing factors. A narrative review with a systematic search was conducted, drawing on the principles of hermeneutic review ( Boell and Cecez-Kecmanovic, 2014 ). A hermeneutic review has two main characteristics:

• accessing and interpreting the literature and
• developing an argument.

The literature search is not only systematic but also flexible and iterative. As the identified literature increases, initial insights and ideas arise and less relevant literature could be rejected through progressive focus. It is argued elsewhere that a narrative review like a hermeneutic review should be the method of choice for interpreting a large and diverse set of literature in which authors have approached the topic differently ( Greenhalgh et al. , 2018 ), as is the objective of our literature review. The review was executed in three steps: definition of scope, systematic search and assessment and analysis of the literature identified. To structure these three steps, a search protocol was developed beforehand.

2.1. Step 1: Establishment of scope

Definition of the search area included the formulation of a set of inclusion criteria. Manuscripts were included if they:

• studied leadership;
• targeted long-term care, nursing home/facility care or elderly care and were thereby applicable to the current nursing home care context;
• behavioral characteristics of leadership;
• effects of leadership; and/or
• factors influencing leadership;
• were published between 2007 and December 2019 (because of the rapidly changing context);
• were written in English; and
• presented research findings of empirical work or reviews.

The search terms were developed through an iterative process in which three researchers were involved. Based on the two main elements of the study objectives – leadership and nursing home care – multiple search terms and combinations were explored in two databases (Pubmed/Medline and EBSCO).

2.2. Step 2: Systematic search

Using the terms described, systematic searches were performed in the PubMed/Medline, Cochrane, Cinahl, PsycInfo and Google Scholar databases. The snowballing technique was also applied: i.e. the reference lists of all articles included were studied to identify any additional relevant literature. After identifying all potentially relevant literature, assessment and analysis of the articles took place.

2.3. Step 3: Assessment and analysis of the literature identified

Assessment and analysis of the literature took place in three steps: the articles were screened based on the title, abstract and full-text to determine inclusion, data extraction took place and analysis was carried out on the articles that had been included.

• Screening on the title, abstract and full-text: All titles and abstracts were screened independently by two researchers to decide whether articles met the inclusion criteria. If the two researchers assessed the article differently, a third researcher was consulted. The full-text of the selected articles was then independently assessed for eligibility by two researchers. Again, a third researcher was consulted if there was any disagreement. For this, the principles of the hermeneutic review were applied, meaning that the inclusion of articles in a later stage (for instance, full-text screening) was stricter due to progressive insights.
• Data extraction: Two types of data were extracted from the articles. First, for each article the author(s), year of publication, journal, title, country, study design and applied methods, sector and organizational level were noted. Second, the main findings of the articles were extracted. The data extraction took place by two researchers, supervised by a third researcher. A fourth researcher was consulted if there was any disagreement.
• Analysis: Descriptive analysis was chosen, as a large and diverse set of articles was included in which leadership was approached and studied differently. As the aim was to build an understanding of leadership, the analysis focused on interpreting the findings of the articles included. Reflection on the content analysis took place with a fourth researcher.

The systematic database search resulted in the identification of 2,332 scientific articles. After removal of duplicates, 2,031 records were screened on title and abstract, based on the formulated inclusion criteria. After this screening 76 scientific articles remained for full-text assessment. During the full-text screening, 36 papers were excluded due to the following reasons: no focus on leadership ( n  =   20), not applicable to the nursing home care context ( n  =   3), leadership only focuses on external stakeholders ( n  =   2), articles report only opinions or vision ( n  =   6), no full text available ( n =  3) and no focus on the interaction between leaders and professionals ( n  =   2). As a result of the “snowballing” technique, 3 extra scientific articles were included. This resulted in a total of 44 included articles. Figure 1 shows the PRISMA flow chart, which displays the systematic literature search process. Table 1 presents the characteristics of the articles, including an overview of study design: 17 qualitative, 16 quantitative, 4 mixed methods and 7 (systematic) reviews were included.

PRISMA flow chart

Characteristics of the articles included

3.1. Leadership behaviors

The articles included in this review describe many sorts of leadership behaviors. In most articles, the studied set of leadership behaviors is given a name/title/term such as “partnered leadership,” “connective leadership” and “adaptive leadership.” In the articles, they are often connected to one of the main leadership styles. Descriptions of leadership behaviors identified are, therefore, distributed over three main categories: relationship-oriented leadership, task-oriented leadership and context-dependent leadership.

Especially more recent articles move away from leadership styles and focus more on behaviors essential for new developments in nursing homes. In the articles of Brodtkorb et al. (2019) and Backman et al. (2018) , important leadership characteristics were identified to support the implementation of person-centered care. Havig and Hollister (2018) focused on the interplay of independent workgroups (resembling self-organization) and appropriate supportive leadership.

3.1.1. Relationship-oriented leadership behavior.

In total, 15 different sorts of leaderships related to relationship-oriented leadership were identified in 34 articles. Transformational leadership was studied the most ( n  =   16), followed by relational leadership ( n  =   7) and the resonant, coaching, consensus and consultative autocratic behavioral styles ( n  =   3). Although “partnered leadership” ( Jennings et al. , 2011 ; Leutz et al. , 2010 ), “individualized consideration” ( Cummings et al. , 2010 ), “authentic leadership” ( Hakanson et al. , 2014 ) and “connective leadership” ( Jennings et al. , 2011 ) were also mentioned as research objectives, no outcomes regarding these behaviors were given in the articles.

When looking more closely at behaviors, the leadership types identified shows a lot of overlap. In relationship-oriented leadership behaviors identified, leaders focus on relationships, using emotional skills such as listening and empathy, to increase the involvement of employees ( Cummings et al. , 2008 ; Forbes-Thompson et al. , 2007 ; Havig et al. , 2011 ; Havig et al. , 2011 ; Jeon et al. , 2015 ). As Havig et al. (2011) describe: “relationship-oriented style constitutes the behaviors of supporting […], developing […] and recognizing” ( Havig et al. , 2011 , p. 2). Transformational leadership aims to create awareness and involvement of employees in line with the objectives of the organization ( Nielsen et al. , 2010 ).

3.1.2. Task-oriented leadership behaviors.

Task-oriented leadership behaviors were studied less extensively. Furthermore, they were often contrasted with relationship-oriented leadership behaviors. In total 9 task-oriented types of leadership were mentioned as study objectives in 9 of the articles included in the review. In most of the articles, no specific characteristics were described.

The similarity between task-oriented and transactional leadership behavior is that it is rational, concise and business-like. Task-oriented leadership deals with the management of tasks and activities (who does what, when and how), distribution of roles, objectives, monitoring and results ( Havig et al. , 2011 ; Havig et al. , 2011 ). Transactional leadership takes transactions between leaders and employees as a starting point ( Cummings et al. , 2010 ). In terms of behavior, this is reflected in rewarding and “punishing” employees. “Shareholder management” is characterized by behavior in which minimal attention is paid to the development of relationships between people ( Havig et al. , 2011 ). Employees work relatively autonomously, there is not much communication and decisions are made centrally. Autocratic leaders also make their own decision, but their employees face a relatively low amount of autonomy ( Castle and Decker, 2011 ; Donoghue and Castle, 2009 ; Havig et al. , 2011 ).

3.1.3. Context-dependent leadership behaviors.

Although the studies in this review focus predominantly on relationship-oriented leadership behaviors, the literature also recommends interpreting with caution. Various studies emphasize that leadership is a complex phenomenon that depends on situations and individuals ( Jennings et al. , 2011 ). Some of the articles conclude that a combination of leadership behaviors is needed. Havig et al. (2011) conclude that a combination of both relationship-oriented and task-oriented leadership behaviors is preferred in their study of job satisfaction in nursing homes ( Havig et al. , 2011 ). Nursing homes with a more hierarchical structure and more mutual interdependence could benefit from task-oriented leadership and vice versa. The authors conclude that leadership is context-dependent. Jennings et al. (2011) state:

The strongest statement that can be made based on empirical studies is that it is unwise to view transformational leadership as a preferred style, particularly when this style is assessed independently of other leadership styles and organizational variables ( Jennings et al. , 2011 , p. 15).

Some leadership behaviors identified in this review embrace this context-dependency and represent a combination of leadership behaviors. Lynch et al. (2011) describe the application of situational leadership to residential care. This is characterized by multiple behaviors of a leader, depending on the situation and the individual. Corazzini and colleagues focus on “adaptive leadership,” which makes a distinction between technical and adaptive challenges ( Corazzini et al. , 2015 ; Corazzini and Anderson, 2013 ). In this context, technical challenges refer to issues that can be easily defined and solved with the appropriate expertise or resources. Adaptive challenges, on the other hand, require new and innovative solutions which may also require a change in values or attitudes. Issues often include both technical and adaptive challenges, in which different leadership behaviors are needed ( Corazzini et al. , 2015 ; Corazzini and Anderson, 2013 ).

Both situational and adaptive leadership is built on the belief that appropriate leadership behaviors should be chosen based on situation and context ( Corazzini and Anderson, 2013 ; Lynch et al. , 2011 , 2018 ). Situational leaders exhibit leadership behavior, which fits with a particular situation and adapts this behavior accordingly to achieve results in a planned way. Central to adaptive leadership, which has roots in complexity theory, is the belief that there are no fixed solutions for complex issues. The behavior of adaptive leaders can, therefore, be characterized as highly flexible and adaptive, to cope with (sudden) changes and developments in complex environments ( Table 2 ).

Leadership styles and their associated characteristics and behaviors

3.2. Reported effects of leadership

In 38 articles effects of leadership were described. The effects of leadership were measured quantitatively in 15 of the articles identified. In 4 articles effects were studied using mixed-methods, in 13 articles effects were measured using qualitative methods and effects were described in 6 reviews. The described effects in the qualitative articles are less “hard” and were not taken into consideration in the table. Reported effects can be separated into five categories: the effects of leadership on:

• quality of care;
• quality of life;
• person-centered care; and
• innovation processes.

Table 3 presents the effects studied in these articles.

Reported effects of leadership

Most studies report that relationship-oriented leadership has a positive impact on employees. Relationship-oriented leadership leads to higher job satisfaction ( Cummings et al. , 2010 ; Donoghue and Castle, 2009 ; Havig et al. , 2011 ; Nielsen et al. , 2010 ), a better relationship with work (for example, a higher organizational commitment) ( Cummings et al. , 2010 ; Donoghue and Castle, 2009 ; Lundgren et al. , 2016 ; Nielsen et al. , 2010 ), higher productivity and effectiveness ( Buljac-Samardzic and van Woerkom, 2015 ; Cummings et al. , 2010 ) and more empowerment and development opportunities ( Cummings et al. , 2014 , 2010 ; Lundgren et al. , 2016 ; Nielsen et al. , 2008 ). Among the articles is one systematic review ( Cummings et al. , 2010 ), in which 53 articles are studied. This study concludes that relationship-oriented leadership is more likely to have positive effects on employees.

In 11 of the articles, the relationship between leadership and quality of care was studied. In these articles, different effects were observed. In four articles no effects were found ( Jeon et al. , 2015 ; Marotta, 2010 ; Olinger, 2010 ; Westerberg and Tafvelin, 2014 ). Four papers conclude that relationship-oriented leadership results in a higher quality of care ( Castle and Decker, 2011 ; Harvath et al. , 2008 ; McKinney et al. , 2016 ; Westerberg and Tafvelin, 2014 ), while in one article it is concluded that a combination of task-oriented and relationship-oriented leadership leads to a higher quality of care (with the emphasis on task-oriented leadership) ( Jennings et al. , 2011 ). Based on their study in Sweden, Westerberg and Tafvelin (2014) present an indirect positive relationship between transformational leadership and quality of care, via mediating variables such as organizational support, support by experienced colleagues, workload and control ( Westerberg and Tafvelin, 2014 ). In all articles quality of care is either not defined consistently or not defined at all. One article studied the impact of leadership on quality of life in the USA. McKinney et al. (2016) report that consensus leadership behavior is “associated with a lower likelihood of deficiencies for quality of life” ( McKinney et al. , 2016 , p. 230).

Furthermore, in three articles a relationship between leadership and person-centered care is described ( Backman et al. , 2016 ; Brodtkorb et al. , 2019 ; Lynch et al. , 2011 ). Backman et al. (2016) for instance conclude that there is a significant relationship between the leadership behavior (of older managers) and person-centered care and psychosocial climate. In this Swedish study, the most appropriate type of leadership and the associated behavior is not specified. Concerning the implementation of person-centered care, Backman et al. (2016) mention “Person-centered care moderates the relationship between leadership behavior” ( Backman et al. , 2016 , p. 8). The authors conclude that leadership is more important in organizations that offer less person-centered care. In these organizations, leaders need to provide direction toward a more person-centered way of working. In line with this, Brodtkorb et al. (2019) revealed: “a close connection between leadership style [participative leadership] and culture change processes toward PCC” ( Brodtkorb et al. , 2019 , p. 134).

On the other hand, a number of studies present contrasting findings or caveats (weak or even no evidence) with respect to the positive effects of relationship-oriented leadership ( Harvath et al. , 2008 ; Havig et al. , 2011 ; Jennings et al. , 2011 ; Jeon et al. , 2015 ; Marotta, 2010 ; Olinger, 2010 ). In a Norwegian study, Havig et al. (2011) report that task-oriented leadership has a more significant impact on the job satisfaction of employees. Also, Jennings et al. (2011) conclude that there is little empirical evidence to relate impacts to certain leadership because leadership is multidimensional and complex: leaders use combinations of leadership behaviors and styles in practice. Olinger (2010) found no statistical significance for nursing home administrator and nursing director leadership styles on care quality.

3.3. Factors influencing leadership

Out of all articles included in this review, 22 articles describe factors that could influence leadership. The influencing factors were identified at three levels: the leader, the team(s) and the organization. Table 4 presents these factors.

Factors influencing leadership

A number of influencing factors – found in seven articles – can be related to the leader him/herself: personal characteristics of the leader ( Cummings et al. , 2008 , 2014 ; Nielsen and Cleal, 2011 ), leadership competencies ( Cummings et al. , 2008 ), educational activities ( Cummings et al. , 2008 ; Hakanson et al. , 2014 ; Vesterinen et al. , 2009 ) and distance to practice ( Havig and Hollister, 2018 ; Kristiansen et al. , 2016 ). The systematic review by Cummings et al. (2008) provides particular insight into the influence of these factors on relational leadership. Cummings et al. state that the personal characteristics of effective leaders relate to openness, extraversion and management motivation. “Significant positive relationships were reported between the leaders’ motivation and their leadership behaviors.” ( Cummings et al. , 2008 , p. 244). Education of leaders, both in relation to professional knowledge and to leadership skills, is mentioned as a positive influencing factor in three articles ( Cummings et al. , 2008 ; Hakanson et al. , 2014 ; Vesterinen et al. , 2009 ). In a Swedish case study, Hakanson et al. (2014) found that leaders identify their own shortcomings and needs for personal development by following educational activities. The specific content of the different educational activities or programs were not described in the articles. A distance to practice was found to be a constraining factor ( Havig and Hollister, 2018 ; Kristiansen et al. , 2016 ). As illustrated by Havig and Hollister (2018) :

They also spent less time at the ward and did not have the same knowledge about their employees’ work situation as the leaders in the high-quality wards. The result of this lack of leadership was often poor work environments, with interpersonal conflicts and frustration, which distracted the care workers and turned their focus away from their daily work duties and the residents ( Havig and Hollister, 2018 , p. 379).

Ten studies showed that team-related factors could influence leadership:

• turnover and absence ( Cloutier et al. , 2016 ; Havig et al. , 2011 );
• interpersonal relations ( Corazzini et al. , 2015 ; Havig and Hollister, 2018 );
• workload ( Corazzini et al. , 2015 ; Westerberg and Tafvelin, 2014 );
• willingness to be coached ( Cummings et al. , 2014 ; Havig et al. , 2011 );
• employee well-being and satisfaction ( Cummings et al. , 2014 ; Nielsen et al. , 2008 );
• self-efficacy ( Nielsen et al. , 2009 ; Nielsen and Munir, 2009 ); and
• interdependent workgroups ( Havig and Hollister, 2018 ).

Two articles relate a high turnover and/or absence rate of employees to less effective leadership ( Cloutier et al. , 2016 ; Havig et al. , 2011 ). In a Western Canadian case study, Cloutier et al. (2016) report that “With greater staff mobility and change, the leadership had less knowledge of their staff to mobilize existing skill sets, use the expertise and build cohesion” ( Cloutier et al. , 2016 , p. 12). Close interpersonal relations – staff/staff, leader/staff and staff/resident – were found to be positively related to leadership ( Corazzini et al. , 2015 ; Havig and Hollister, 2018 ). In turn, a high workload was negatively related ( Corazzini et al. , 2015 ; Westerberg and Tafvelin, 2014 ). Also, the (un)willingness of teams to be coached was mentioned as an influencing factor ( Cummings et al. , 2014 ; Nielsen et al. , 2008 ). Cummings et al. illustrate this as follows:

“Some managers reported out that some of their staff have little interest in learning new things and updating their skills and knowledge,” as per the following quote: “They just want to do their job and go home.” […] A manager, who considered coaching uninterested staff to be undesirable, reported: “Not wanting to rock the boat (don’t have time to risk losing that staff)” ( Cummings et al. , 2014 , p. 205).

Furthermore, employee well-being and satisfaction were stated as potential influencers of leadership. Although there is limited evidence of the direct relationship between leadership behavior and well-being ( Nielsen et al. , 2008 ), two articles mention that a higher level of job satisfaction corresponds to more effective leadership ( Cummings et al. , 2014 ; Nielsen et al. , 2008 ). Finally, Havig and Hollister (2018) found that independent workgroups (or teams) of caregivers, which had their own meetings, reports and administrator, could have a possible influence on nursing home quality. Their analysis revealed that workgroups were fostered by three mediators, namely, psychological ownership, perceived insider status and shared mental models.

In total, 20 articles described factors that influence leadership at an organizational level. The following factors were identified in this category:

• organizational structure ( Corazzini et al. , 2015 ; Cummings et al. , 2008 , 2014 ; Lundgren et al. , 2016 ; Rokstad et al. , 2015 );
• the extent to which person-centered care has been implemented ( Backman et al. , 2016 , 2020 );
• organizational culture ( Ali and Terry, 2017 ; Backman et al. , 2020 ; Corazzini et al. , 2015 ; Havig and Hollister, 2018 ; Jeon et al. , 2010 ; Nielsen et al. , 2008 ; Vesterinen et al. , 2009 );
• the available information and information flow ( Forbes-Thompson et al. , 2007 ; Hakanson et al. , 2014 ; Jeon et al. , 2010 ; Vesterinen et al. , 2009 );
• previous leaders ( Vesterinen et al. , 2009 );
• available budget and time ( Ali and Terry, 2017 ; Cummings et al. , 2014 ; Hakanson et al. , 2014 ; Nielsen et al. , 2010 ; Rokstad et al. , 2015 );
• tasks and responsibilities ( Hakanson et al. , 2014 ; Jeon et al. , 2010 ; Kristiansen et al. , 2016 ; Nielsen et al. , 2008 );
• the leadership team ( Hakanson et al. , 2014 ; Vesterinen et al. , 2009 );
• organizational dynamics and stability ( Jeon et al. , 2010 ; Nielsen et al. , 2010 ; Nielsen and Cleal, 2011 );
• support from superiors ( Jeon et al. , 2010 ; Westerberg and Tafvelin, 2014 ); and
• openness to change and innovations ( Brodtkorb et al. , 2019 ; Jeon et al. , 2010 ; Lynch et al. , 2011 ; Nielsen et al. , 2008 ).

First, the structure of an organization was found to influence the way in which leadership is performed. In bigger organizations, for instance, there is often more distance between managers and the work floor than in smaller organizations and this creates challenges to performing direct, relational leadership ( Lundgren et al. , 2016 ; Rokstad et al. , 2015 ). As Lundgren et al. state:

Physical distance between leaders and subordinates reduces the opportunity for leaders to supervise, organize and optimize nursing assistants’ work situations, which may have negative effects in the field of home help services ( Lundgren et al. , 2016 , p. 51).

In a Finnish qualitative study, Vesterinen et al. (2009) report that organizational culture and information available for employees influence leadership:

The managers said that their leadership style was influenced by the flow of information in the organization. It was difficult to lead others toward a vision when there was a lack of information ( Vesterinen et al. , 2009 , p. 508).

Other influencing factors include tasks and responsibilities of leaders ( Hakanson et al. , 2014 ; Kristiansen et al. , 2016 ) and available budget and time. Although they emphasize that leadership depends on situations and people, Nielsen and Cleal (2011) relate a stable organization (low staff turnover, financially stable, no reorganizations) positively to (transformational) leadership.

4. Discussion

As a result of analysis of the academic literature currently available, the findings of this study provide insight into leadership behaviors, their effects and factors influencing them. When looking into what kind of leadership is considered appropriate in the nursing home care context, also considering its current developments, our analysis does not provide an unambiguous answer. Our review shows that leadership in nursing home care is a complex and multidimensional undertaking, influenced by multiple internal and external factors. On the one hand, there is a tendency toward relationship-oriented and transformational leadership in particular. Our search identified 15 different sorts of leadership related to relational leadership with many reported positive effects on health-care professionals, quality of care, quality of life and person-centered care. However, a diversity of measures was used, with a variety in quality. Both quantitatively and qualitatively observed effects were considered. On the other hand, contrasting findings have also been reported, for example, both positive and negative effects on job satisfaction associated with task-oriented leadership ( Cummings et al. , 2010 ; Havig et al. , 2011 ). Also, various studies emphasized that “good” leadership cannot be achieved by applying only one type of leadership behavior. Both relationship-oriented and task-oriented leadership have resulted in positive effects, as demonstrated by the evaluation of job satisfaction in nursing homes ( Havig et al. , 2011 ). Furthermore, as a broad scope was used to comprehensively identify insights applicable in nursing home care, the studies compared in this review were carried out in different contexts (for example, nursing homes, long-term care, facility care, etc.) in different countries using different methodologies. For example, in the studies included in which a relationship between leadership and quality of care was reported, different definitions of quality of care were used and there was no differentiation between specific aspects of quality of care ( Castle and Decker, 2011 ; Havig et al. , 2011 ; Marotta, 2010 ; McKinney et al. , 2016 ; Olinger, 2010 ; Westerberg and Tafvelin, 2014 ). Therefore, it is also difficult to interpret and compare the results of these studies. This makes it hard to draw any meaningful conclusions about the effects of certain leadership. Another complicating factor in the identification of appropriate leadership is that leadership is a product of multiple influencing factors. Our review identified 22 influencing factors at the individual, team and organizational levels. This shows that leadership in nursing home care is not only complex and multidimensional but may also be influenced by internal and external factors. As a consequence, when looking for appropriate leadership, the answer does not lie in one type of leadership.

This observation is also reflected in some of the articles included in the review. Although a relationship-oriented style was the basis for investigation in most of the studies analyzed, some of them report that certain contexts and situations demand more task-oriented behaviors. Furthermore, literature also shows that the combination of both styles may be appropriate. A balanced mix of leadership styles, for instance, a relationship-oriented focus combined with task-oriented behaviors, is also advocated in other sectors outside nursing home care. Mintzberg (2009) , for example, cites the broad variety of leadership styles in the literature and emphasizes that the application of one style may lead to management that is not in balance ( Mintzberg, 2009 ). Furthermore, in their study on leadership patterns and their effects on employee satisfaction and commitment, Gavan O’Shea et al. (2009) conclude that effective leaders use a combination of styles ( Gavan O’Shea et al. , 2009 ). This was also the conclusion reached by Aarons (2006) specifically with respect to the mental health sector ( Aarons, 2006 ).

While our analysis shows a tendency in favor of combinations of elements from different types of leadership to deal with different situations and contexts, many included studies explore relationships between relational and task-oriented leadership only in a bivariate way. As Cummings et al. (2010) conclude:

In our analyzes, we had simplified the pattern of two approaches to leadership styles and their impact on specific outcomes for nurses, the nursing environment and the nursing workforce. In reality, leadership practices, behaviors and styles and outcomes are not that clean-cut ( Cummings et al. , 2010 , p. 17).

This awareness demonstrates that a greater focus on leadership behaviors in relation to contextual factors rather than leadership styles could provide more valuable insight into appropriate leadership in nursing home care. In most of the literature reviewed, however, leadership behavior is not described or explained precisely. Fortunately, more recent literature is moving away from studying solely leadership styles and is focusing more on appropriate leadership behavior for new developments, like the implementation of Dementia Care Mapping and person-centered care ( Backman et al. , 2020 ; Lynch et al. , 2018 ; Quasdorf and Bartholomeyczik, 2019 ).

Another point worthy of reflection is that the results of our study show a broad variety of leadership terms, styles and names and a large degree of overlap between their characteristics. This is especially the case in the field of relationship-oriented leadership. It is debatable whether these different definitions of leadership really encompass different behaviors or only use different terminology.

Considering that a focus on leadership behaviors could provide more insight into effective leadership in nursing home care, it is interesting to ask what leadership behaviors will be appropriate with respect to the current developments in nursing home care. First of all, the nursing home care sector could be considered as a complex adaptive system (CAS), in which the connected elements of the system evolve and adapt continuously ( Meadows, 2008 ). The current developments, with tendencies toward decentralization, self-organization and person-centered care, are examples of this evolving and adapting system. While the nursing home care sector consists of many different entities and a high level of interactivity, nursing homes can also be considered as systems in which organizational dynamics take place ( Ashmos et al. , 2000 ). The consequence of leadership behavior is that it is important to be aware that employees are part of a complex system, both in the organization and in the health system as a whole. As complexity scientists ( Lichtenstein et al. , 2006 ) reflect: “leadership is a dynamic that transcends the capabilities of individuals alone; it is the product of interaction, tension and exchange rules governing changes in perceptions and understanding.” ( Lichtenstein et al. , 2006 , p. 2). In this complex environment, it is important to reflect continuously and analyze the suitability of leadership behaviors in different contexts and situations. Corazzini et al. (2015) elaborate on this in their study about adaptive leadership and they conclude that problems in nursing homes are mostly complex and cannot be solved by one type of leader.

Furthermore, current developments toward flat organizations, decentralization and self-direction, show a tendency toward more collective responsibility and ownership at all layers of organizations. Most papers included in this review addressed a specific organizational level. A number of studies focus on leadership in middle management ( Buljac-Samardzic and van Woerkom, 2015 ; Corazzini and Anderson, 2013 ; Hakanson et al. , 2014 ; Leutz et al. , 2010 ; Nielsen et al. , 2010 ; Nielsen and Cleal, 2011 ; Oldenhof et al. , 2016 ; Vesterinen et al. , 2009 ) and only one article is specifically taking independent workgroups (teams) into account ( Havig and Hollister, 2018 ). Other articles cover board/management level and some do not focus on a specific organizational level. In the light of current developments in nursing home care, taking new organizational structures with decentralized collective responsibilities such as self-directed teams, into account, a focus on leadership across multiple layers of nursing homes would provide more detailed insights into leadership behaviors and the complex interaction between people and situations. It is striking that the current review did only identify one article that focused specifically on these issues.

4.1. Research limitations and implications

The literature review was carried out in a structured and systematic way. Six systematic reviews were used in this study, which included 255 articles in total (including several studies published before January 1, 2007). This provided a strong theoretical basis, including insights into a broader context. Because the leadership literature is extensive, only articles applicable to nursing home care were included. On the one hand, the current tendencies and insights in leadership literature are well represented in the literature applicable to nursing home care. On the other hand, the leadership literature in this sector is still relatively new. This may yield articles that take an exploratory approach. Also, the definition of “nursing home care” may differ between countries as will the services or care which are captured under this term. Furthermore, relevant insights in nursing home care are often shared in non-academic documents or grey literature. This study only focused on the academic literature. This “publication delay” could explain that literature on relatively new leadership-related tendencies such as self-organization, self-management and autonomous teams, was not available.

The results of this study show that a broad range of leadership behaviors is evident in nursing home care. Further investigation of behaviors that match particular contexts or situations would be relevant. The behaviors identified in this review provide insight into leadership in nursing home care, but more research is needed on how this is reflected in practice. Characteristics such as involvement and appreciation mainly focus on the result of leadership behavior, while more knowledge could be gained about how to actually achieve this. Future research should focus on strategies and methods for the translation of leadership into behavior in practice. Another relevant avenue of research is the impact of cultural aspects on leadership. Research demonstrates that leadership-related culture and values may differ across settings and countries ( Ardichvili and Kuchinke, 2002 ; Chhokar et al. , 2007 ; Hofstede, 2011 ). Examples are power distance, masculinity, uncertainty avoidance and long-term orientation ( Hofstede, 2011 ). These core values could influence leadership approaches and behaviors in practice. Our review includes studies from various, mainly Western, countries such as the USA, Canada, Australia, England and multiple Scandinavian countries. The included articles do not explicitly reflect on the cultural aspects of leadership. More insight into what the exact impact of these aspects is would be relevant. Finally, an interesting research question would be to compare how leadership behavior is perceived by the different people involved. The role of informal leadership and the dynamics in collaborating networks could also be interesting topics for further research.

5. Conclusions

In conclusion, because leadership in nursing home care is multidimensional and influenced by multiple factors, no specific type of leadership can be considered as most appropriate. Furthermore, this review showed a high level of overlap between the behaviors of the many types of leadership presented in the articles included. It is, therefore, questionable whether leadership styles are a useful vocabulary in the debate on leadership in nursing homes. Moreover, the current tendency toward flat organizations, decentralization and self-direction transforms leadership into a more collective undertaking that transcends hierarchy and encompasses behavior, context and people. Tendencies toward networks of collaborating organizations require new leadership competencies that transcend organizational boundaries and interests. Therefore, a stronger focus on leadership behaviors in relationship to specific contexts instead of the application of leadership styles could provide more insight into what is needed when and what works.

The findings of this study show that leadership is a complex and multidimensional phenomenon, which is determined by multiple internal and external factors. Employees of nursing homes have to be aware that the success of leadership is determined by the interplay between behavior and several contextual factors and the various people involved. Furthermore, the study findings suggest focusing more on leadership behaviors instead of styles. Although thinking in leadership styles could be helpful in terms of categorization and framing, a broader and more conceptual perspective on leadership could be helpful in providing more insight into the underlying mechanisms and behaviors that play a role in leadership. First, a broader perspective implies that leadership should be seen as more than merely a function for managers and team leaders ( Martin and Learmonth, 2012 ). It should be constructed as something to be enacted by all employees across an organization. Second, the broader perspective also means that one has to be aware that leadership processes take place at multiple layers in an organization, e.g. in the care setting, in professional interaction or at the board level. Third, people in organizations could benefit from more awareness of their leadership behavior and how this fits with the current context, circumstances and developments.

Acknowledgments

Funding : The research is funded by the Dutch Ministry of Health as part of the W&T Program. The Ministry of Health had no role in the design of the study and collection, analysis and interpretation of data and in writing the manuscript.

Competing interests : The authors declare that they have no competing interests.

Availability of data and materials: The data sets used during the current study are available on request.

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Chronic Understaffing in Nursing Homes and the Impacts on Healthcare

• Understaffing in nursing homes has been a dangerous problem since the 1980s, and nursing homes have been aware of it.
• The COVID-19 pandemic worsened the understaffing issues in nursing homes.
• Nursing home administrators and staff can all be part of the solution.

Working in a nursing home became the most dangerous job in America when the COVID-19 pandemic started, according to U.S. News and World Report .

The COVID-19 pandemic heightened the nursing shortage happening across healthcare. However, the shortage of nurses in nursing homes has been chronic for decades. Staff-to-patient ratios were already at a dangerous level.

The pandemic came and worsened the causes of the shortage. Now, in the face of imperfect solutions, nursing homes struggle to hire and retain quality staff and keep their doors open.

COVID-19 Worsened the Nursing Shortage in Nursing Homes

Nursing homes already struggled to hire and keep staff before COVID-19. Poor pay, lack of respect, unsafe conditions, and unreasonable workloads worsened when the pandemic hit.

Despite certified nursing assistants (CNAs) making up the majority of the nursing home workforce and providing most of the direct nursing care for residents, CNAs are paid the least and are the most at risk for work-related injuries, according to the American Association of Retired Persons (AARP).

What’s more, nursing home workers provided the same physically and emotionally demanding care, but in more hazardous conditions and with a smaller staff.

The COVID-19 pandemic added infection control issues to the staffing shortage. About 20% of nursing homes did not have enough personal protective equipment (PPE), according to Brian E. McGarry et al. in October 2020. Nursing home workers reused PPE or used inadequate quality PPE while providing care to patients with and without COVID-19.

The staff turnover rate before the pandemic was 94%, according to Health Affairs data from 2017 and 2018. During the pandemic, nursing home staff quit at higher rates than any other healthcare professional because they were unwilling or unable to work in unsafe conditions.

According to the American Health Care Association , as of June 2022, nursing homes still had dire understaffing levels on several fronts:

• 87% of nursing homes experience moderate or high staffing shortages
• 98% of nursing homes face issues hiring new staff
• 73% of nursing homes may have to close due to staffing shortages
• 60% of nursing homes are losing money
• 53% of nursing homes cannot operate with their current costs and pace for more than a year

Nursing Homes Experience Low Staff-to-Patient Ratios for Decades

In 2001, Centers for Medicare and Medicaid Services published a study establishing the importance of minimum staff-to-patient ratios in nursing homes. The study suggests that nurses provide each nursing home resident with at least 4.1-4.85 hours of direct nursing care per day, depending on how long the resident stays in the nursing home.

These minimum hours should include a mix of care from registered nurses (RNs), licensed practical nurses (LPNs), and CNAs in varying amounts.

Because of poor funding, high staff turnover and burnout, and unsafe working conditions, many nursing homes do not meet these minimum standards. However, there are few consequences if nursing homes fall short of these safe-staffing standards. Nursing homes can remain open, and nursing home staff can keep their licenses.

Nursing homes and their staff will only face consequences if short staffing causes harmful outcomes for patients. Some of these harmful patient outcomes that can cause nursing staff to lose their licenses and become civilly and criminally liable include:

• Hospitalizations
• Emergency room visits

To complicate things further, 30 states established their own mandatory minimum number of hours of direct nursing care per resident per day. All 30 states mandate fewer hours of direct nursing care than the national recommendation.

These state requirements are well below the individual healthcare needs of each resident. Nursing homes can also apply for waivers, provided by Congress , rather than meet the requirements in some cases.

The Role of Lawmakers in Nurse Staffing Ratios

Congress does not lay out specific rules for how much staff a nursing home needs to hire. Congress currently only requires long-term care facilities to provide:

• Enough staff, including licensed nurses and CNAs, to meet the needs of all residents, according to their care plans
• An RN, who serves as the director of nursing on a full-time basis
• An RN, who serves as a full-time charge nurse
• An RN for eight consecutive hours and seven days a week
• CNAs, who show proficiency in skills they perform, get their license within four months of hire, and register with their state within four months of hire

Because Congress has not set mandatory minimum staffing requirements yet, states have taken it upon themselves to dictate staffing requirements. New York, Rhode Island, and Massachusetts increased their mandatory minimum staffing requirements. Other states such as Georgia, Oregon, and South Carolina temporarily or permanently decreased their requirements.

Mandatory staffing minimums may help staff-to-patient ratios, but currently, Congress has not set one. And states cannot agree on how many staff members should be required.

Nursing Homes Know the Risk of Low Nurse-to-Patient Ratios

Nursing homes have known about the dangers of short staffing since the 1980s. Yet, sometimes, they intentionally hire fewer people to cut labor costs.

According to Kaiser Health News, many nursing homes inaccurately represented how many people they had on the payroll and got away with it too. That is, until the Affordable Care Act in 2010 required nursing homes to turn in their daily payroll reports as a way to verify how many people were on staff.

About half of nursing homes failed to meet CMS recommendations for total staff 80% or more of the time between April 2017 and March 2018, according to Health Affairs data from July 2019.

Payroll data shows that all types of nursing homes did not meet CMS recommendations for the average hours spent with each resident. The average number of hours spent with each resident per day in for-profit nursing homes failed to meet even the lower requirements of the states, such as the 3.5 hours that California law requires.

LPNs do not face the challenges of poor pay, physically demanding work, and lack of advancement as much as RNs and CNAs do. In fact, nursing homes were mostly likely to staff the required number of LPNs.

Skilled nursing facilities pay LPNs the highest average annual salary, according to data from the U.S. Bureau of Labor Statistics (BLS), and they are not expected to do as much physical work as CNAs.

However, along with CNAs, nursing homes also offer poorer-than-average salaries for RNs , according to BLS data.

RNs may have more opportunities for advancement in other healthcare settings compared to CNAs. For CNAs, the physical demand of working in nursing homes is higher than if they choose to work in home health or assisted living.

Causes of the Staffing Shortage

• Lack of respect for the work they do
• Poor pay and benefits
• Limited career advancement opportunities
• Better-paying opportunities in other industries or healthcare settings
• Unsafe working conditions and workloads

Effects of the Staffing Shortage

• High turnover
• High nurse burnout
• Unsafe working conditions
• Increased workload and overtime hours
• Unsafe staff-to-patient ratios

What to Do About Low Staff-to-Patient Ratios?

Insufficient staff-to-patient ratios do not have an easy solution. Nursing homes get most of their funding from Medicare and Medicaid. CMS reimburses nursing homes with a bundled payment system, so nursing homes receive one lump sum per patient per day.

The nursing home decides, based on the patient’s needs, the most important care for the patient. Many specialties fighting for a single pot of money means smaller salaries for staff and limited funds to hire new staff. Patients may not get care from all the specialties they need or for as long as they need.

Nursing homes solutions are incomplete and imperfect. Government officials from both political parties have tried to improve the quality and cost of nursing homes for decades with little success.

The most successful and workable solution will likely involve a mix of solutions from staff and nursing home leadership.

Congress could make a law that requires nursing homes to give each resident 4.1-4.85 hours of direct care per day. However, the law would be difficult to enforce.

The minimum staff requirements that some states passed may help patients, but a flat number of staff may not help patients who need more attention or direct care than average. Nursing homes can and have worked around minimum staffing rules by hiring temporary staff right before inspection.

Nursing homes try many different solutions to get more staff. However, they face issues because of the poor reimbursement rates and the lack of qualified or interested candidates.

To try to cope with the staff shortage, nursing homes may:

High levels of turnover and burnout create an endless loop of staffing shortage in nursing homes. Nursing homes need good-quality CNAs, LPNs, and RNs to decrease the workload and make working conditions safer. Yet, good quality CNAs, LPNs, and RNs will find jobs elsewhere as long as nursing homes have such high workloads and unsafe conditions.

Nursing staff should help each other out when they can and make the most of the few resources they have. They should stick up for themselves, their coworkers, and their patients to minimize harm.

42 CFR § 483.35 — nursing services. (n.d.). https://www.law.cornell.edu/cfr/text/42/483.35

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Feuerberg M. (2001). Appropriateness of minimum nurse staffing ratios in nursing homes. https://www.justice.gov/sites/default/files/elderjustice/legacy/2015/07/12/Appropriateness_of_Minimum_Nurse_Staffing_Ratios_in_Nursing_Homes.pdf

Gandhi A, et al. (2021). High nursing staff turnover in nursing homes offers important quality information. https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.00957

Geng F, et al. (2019). Daily nursing home staffing levels highly variable, often below CMS expectations. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.05322

Harrington C, et al. (2020). Appropriate nurse staffing levels for U.S. nursing homes.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328494/

McGarry BE, et al. (2020). Severe staffing and personal protective equipment shortages faced by nursing homes during the COVID-19 pandemic. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7598889/

Paulin E. Inside the ‘staffing apocalypse’ devastating U.S. nursing homes.

https://www.aarp.org/caregiving/health/info-2022/labor-shortage-nursing-homes.html

Pickering CEZ, et al. (2017). Recognizing and responding to the “toxic” work environment: Worker safety, patient safety, and abuse/neglect in nursing homes.

https://www.researchgate.net/publication/319110552_Recognizing_and_Responding_to_the_Toxic_Work_Environment_Worker_Safety_Patient_Safety_and_AbuseNeglect_in_Nursing_Homes

Rau J. (2018). ‘Like a ghost town’: Erratic nursing home staffing revealed through new records.

https://khn.org/news/like-a-ghost-town-erratic-nursing-home-staffing-revealed-through-new-records/

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Understaffing in nursing homes. (2022). https://www.nursinghomeabuse.org/nursing-home-neglect/understaffing/#:~:text=The%20most%20significant%20way%20to,at%20nursing%20homes%20are%20appropriate/

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U.S. Bureau of Labor Statistics, Occupational Outlook Handbook. (2021). Registered nurses. https://www.bls.gov/oes/current/oes291141.htm

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What working in a nursing home taught me about life, death, and America’s cultural values

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The first thing I noticed when I began working in a nursing home was the smell. It's everywhere. A mix of detergent and hospital smell and, well, people in nursing homes wear diapers. It's one of those smells that takes over everything — if you're not used to it, it's hard to think about anything else.

Being in the nursing home is tough. People weep and smell and drool. Sometimes you can go on the floor and hear a woman in her 90s scream, "I want Mommy."

But it's also ordinary — just people living together: gossiping, daydreaming, reading, watching TV, scratching their back when it itches.

For the past eight months I have been working as a psychotherapist with dying patients in nursing homes in New York City. It's an unusual job for a psychotherapist — and the first one I took after graduating with a PhD in clinical psychology. My colleagues were surprised. "Why not a hospital? Or an outpatient clinic? Do the patients even have a psychiatric diagnosis?"

The short answer is that I wanted to see what death looks and feels like — to learn from it. I hope that I can also help someone feel a little less lonely, a little more (is there a measure to it?) reconciled.

I haven't gotten used to the smell yet. But I have been thinking a lot about the nursing home and the people who live and die there, and wanted to share what I learned.

1) At the end, only the important things remain

"This is all I have left," a patient recently told me, pointing to a photograph of himself and his wife.

It made me notice the things people bring to the nursing home. The rooms are usually small, so what people bring is important to them. If they have a family, there will be photos of them (most popular are the photos of grandchildren). There might also be a few cherished books, a get-well-soon card, a painting by a grandchild or a nephew, some clothes, maybe flowers. And that's about it. The world shrinks in the nursing home, and only a few things remain: things that feel important — like they're worth fighting for, while we still can.

2) Having a routine is key to happiness

More on dying well.

It's never too early to start thinking about your own death

I'm a little lazy. My ideal vacation is doing nothing, maybe on a deserted beach somewhere. I look in terror upon very scheduled, very planned people. Yet I have been noticing that doing nothing rarely fills me with joy, while doing something sometimes does. Hence, the conflict: Should I push myself to do things, or should I go with the flow and do things only when I feel like doing them? Being in a nursing home changed my perspective somewhat: I noticed that all the patients who do well follow a routine. Their routines are different but always involve some structure and internal discipline.

I am working with a 94-year-old woman. She wakes up at 6:30 am every day, makes her bed, goes for a stroll with a walker, eats breakfast, exercises in the "rehabilitation room," reads, eats lunch, naps, goes for another walk, drinks tea with a friend, eats dinner, and goes to bed. She has a well-defined routine. She pushes herself to do things, some of which are very difficult for her, without asking herself why it is important to do them. And, I think, this is what keeps her alive — her movement, her pushing, is her life.

Observing her, I have been coming to the conclusion that it might be true for all of us. And I often think about her when I am debating whether to go for a run or not, whether to write for a couple more hours or not, whether to finally get up from the couch and clean my apartment or not — she would do it, I know, so maybe I should, too.

3) Old people have the same range of emotions as everyone else

"You are so handsome. Are you married?" is something I hear only in extended-family gatherings and in nursing homes. People flirt with me there all the time. This has nothing to do with their age or health — but rather with whether they are shy. When we see someone who is in his 90s and is all bent and wrinkled and sits in a wheelchair, we might think he doesn't feel anything except physical pain — especially not any sexual urges. That's not true.

As long as people live, they feel everything. They feel lust and regret and sadness and joy. And denying that, because of our own discomfort, is one of the worst things we can do to old people.

Patients in nursing home gossip ("Did you know that this nurse is married to the social worker?"), flirt, make jokes, cry, feel helpless, complain of boredom. "What does someone in her 80s talk about?" a colleague asked me. "About the same things," I replied, "only with more urgency."

Some people don't get that, and talk to old people as if they were children. "How are we today, Mr. Goldstein?" I heard someone ask in a high-pitched voice of a former history professor in his 80s, and then without waiting for a response added, "Did we poopie this morning?" Yes, we did poopie this morning. But we also remembered a funny story from last night and thought about death and about our grandchildren and about whether we could sleep with you because your neck looks nice.

4) Old people are invisible in American culture

People at the nursing home like to watch TV. It's always on. How strange, then, that there are no old people on TV.

Here's a picture I see every day: It's the middle of the day and there is a cooking show or a talk show on, and the host is in her 50s, let's say, but obviously looks much younger, and her guest is in his 30s or 50s and also looks younger, and they talk in this hyper-enthusiastic voice about how "great!" their dish or their new movie is, or how "sad!" the story they just heard was. Watching them is a room full of pensive people in their 80s and 90s who are not quite sure what all the fuss is about. They don't see themselves there. They don't belong there.

I live in Brooklyn, and I rarely see old people around. I rarely see them in Manhattan, either. When I entered the nursing home for the first time I remember thinking that it feels like a prison or a psychiatric institution: full of people who are outside of society, rarely seen on the street. In other cultures, old people are esteemed and valued, and you see them around. In this manic, death-denying culture we live in, there seems to be little place for a melancholic outlook from someone that doesn't look "young!" and "great!" but might know something about life that we don't.

There isn't one Big Truth about life that the patients in the nursing home told me that I can report back; it's a certain perspective, a combination of all the small things. Things like this, which a patient in her 80s told me while we were looking outside: "Valery, one day you will be my age, God willing, and you will sit here, where I sit now, and you will look out of the window, as I do now. And you want to do that without regret and envy; you want to just look out at the world outside and be okay with not being a part of it anymore."

5) The only distraction from pain is spiritual

Some people in the nursing home talk about their physical pain all the time; others don't. They talk about other things instead, and it's rarely a sign of whether they are in pain or not.

Here's my theory: If for most of your life you are concerned with the mundane (which, think about it, always involves personal comfort) then when you get old and feel a lot of pain, that's going to be the only thing you're going to think about. It's like a muscle — you developed the mundane muscle and not the other one.

And you can't start developing the spiritual muscle when you're old. If you didn't really care about anything outside of yourself (like books, or sports, or your brother, or what is a moral life), you're not going to start when you're old and in terrible pain. Your terrible pain will be the only thing on your mind.

But if you have developed the spiritual muscle — not me, not my immediate comfort — you'll be fine; it will work. I have a couple of patients in their 90s who really care about baseball — they worried whether the Mets were going to make the playoffs this year, so they rarely talked about anything else; or a patient who is concerned about the future of the Jewish diaspora and talks about it most of our sessions; or a patient who was worried that not going to a Thanksgiving dinner because of her anxieties about her "inappropriately old" appearance was actually a selfish act that was not fair to her sister. Concerns like these make physical pain more bearable, maybe because they make it less important.

6) If you don't have kids, getting old is tough

The decision to have kids is personal, and consists of so many factors: financial, medical, moral, and so on. There are no rights or wrongs here, obviously. But when we are really old and drooling and wearing a diaper, and it's physically unpleasant to look at our wounds or to smell us, the only people who might be there consistently, when we need them, are going to be either paid to do so (which is okay but not ideal) or our children. A dedicated nephew might come from time to time. An old friend will visit.

But chances are that our siblings will be very old by then, and our parents will be dead, which leaves only children to be there when we need it. Think about it when you are considering whether to have children. The saddest people I see in the nursing home are childless.

7) Think about how you want to die

José Arcadio Buendía in One Hundred Years of Solitude dies under a tree in his own backyard. That's a pretty great death.

People die in different ways in the nursing home. Some with regrets; others in peace. Some cling to the last drops of life; others give way. Some planned their deaths and prepared for them — making their deaths meaningful, not random. A woman in her 90s recently told me, "Trees die standing tall." This is how she wants to go: standing, not crawling.

I think of death as a tour guide to my life — "Look here; pay attention to this!" the guide tells me. Maybe not the most cheerful one, slightly overweight and irritated, but certainly one who knows a lot and can point to the important things while avoiding the popular, touristy stuff. He can tell me that if I want to die under a tree in my backyard, for example, it might make sense to live in a house with a backyard and a tree. To you, he will say that if you don't want any extra procedures done to you at the end, it might make sense to talk about it with the people who will eventually make this decision. That if you want to die while hang-gliding over an ocean, then, who knows, maybe that's also possible.

My father, who has spent the past 30 years working in an ICU as a cardiologist and has seen many deaths, once told me that if he had to choose, he would choose dying well over living well — the misery of a terrible, regretful death feels worse to him than a misery of a terrible life, but a peaceful death feels like the ultimate reward. I think I am beginning to see his point.

I am 33. Sometimes it feels like a lot — close to the end; sometimes, it doesn't. Depends on the day, I guess. And like all of us, including the people in the nursing home, I am figuring things out, trying to do my best with the time I have. To not waste it.

Recently, I had a session with a woman in her 90s who has not been feeling well.

"It's going in a very clear direction," she told me. "Toward the end."

"It's true for all of us," I replied.

"No, sweetheart. There is a big difference: You have much more time."

Valery Hazanov, PhD , is a clinical psychologist in Brooklyn. He is writing a book about his training to become a psychotherapist.

First Person is Vox's home for compelling, provocative narrative essays. Do you have a story to share? Read our submission guidelines , and pitch us at [email protected] .

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Ethical Issues in Long-term Care: A Human Rights Perspective

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• Volume 2 , pages 86–97, ( 2017 )

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Nursing home residents do not relinquish human rights just because they need care. In nursing homes in the USA, federal law guarantees certain rights to residents. This article provides a broader context for understanding the federal resident rights in the USA by examining them within the context of the United Nations Universal Declaration of Human Rights and the National Association of Social Workers Code of Ethics. In the USA, resident, family, and staff education of resident rights is typically the social worker’s responsibility. Two challenges, both of which can lead to ethical dilemmas and human rights violations, are discussed: substance use and resident-to-resident aggressive behavior. Social workers have an important role in developing sound organizational policies which support resident rights and in educating and supporting staff, families, and residents in understanding these rights with the intention of preventing conflicts when possible and addressing conflicts when necessary. Because many long-term nursing home residents will spend their remaining months or years within the nursing home, the home becomes their world where their rights should be respected and realized.

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Introduction

Worldwide, the majority of older adults live independently or with minimal assistance in the community as they have for decades. That said, it is also true that the need for assistance increases with advancing age. Many (but not all) adults over the age of 80 require assistance in performing daily activities due to increased frailty associated with physical or cognitive changes. The United Nations projects that the number of persons age 80 and older worldwide will increase from 125 million in 2015 to 434 million in 2050 (United Nations 2016 ). Throughout the world, when older adults require assistance in daily living, in most cases, families (generally women) respond to meet these needs, often with the assistance of neighbors, friends, or local organizations, if available. In more industrialized countries, when older adults need more assistance than is available through their family, some turn to nursing homes.

The focus of this article is the rights of people who live in nursing homes in the USA. Through the lens of human rights, resident rights, and ethical principles, we examine two common issues in nursing homes: substance use and resident-to-resident aggression. Each threatens the rights and the quality of life of residents. After describing characteristics of nursing homes and nursing home residents in the USA, we discuss the federal nursing home resident rights and the NASW Code of Ethics before connecting these two documents to the UN Universal Declaration of Human Rights. The second part of the paper examines the two issues by linking them to principles that can assist social workers in addressing these and other challenging issues.

Nursing Homes in the USA

The definition of a nursing home varies from country to country. In the USA, the federal government uses the term “nursing facility” to refer to organizations that provide long-term custodial care that goes beyond room and board and uses the term “skilled nursing facility” to refer to nursing facilities that also provide skilled nursing and rehabilitative services, generally on a short-term basis (Social Security Administration 2017 ). Most facilities in the USA provide both long-term and skilled nursing care services. There are over 15,000 nursing homes in the USA, and over 95% are certified to receive government funding through the Medicare and/or Medicaid programs for the services they provide to residents. Medicare is health insurance for persons, who are entitled to social security payments and have reached age 65 or are disabled, and pays towards the cost of short-term rehabilitative care. Medicaid is a means-tested social program that helps pay for the cost of long-term care. Most people cannot afford the high cost of nursing home care—estimated in 2015 to be about $91,250 per year (Genworth 2015 )—and eventually turn to the Medicaid program for public assistance. Medicaid is the largest payer towards long-term care costs in the USA (Reaves & Musumeci 2015 ).

Seventy percent of nursing homes are for-profit businesses and 6% are government owned; the remaining 24% are not-for-profit organizations (CMS 2015 ). Nearly half (44%) of the nursing homes in the USA have fewer than 100 beds (CMS 2015 ). This is particularly relevant because only nursing homes with more than 120 beds are required to employ a full-time social worker (CFR 2017 , Title 42, part 483), although most nursing homes, even those with fewer than 120 beds, currently do hire at least one social worker (Bern-Klug et al. 2009 ; NCHS 2015 ). Unlike all other health care settings that receive federal funds, according to federal regulations, nursing homes can hire people without a social work degree to serve as the facility’s social worker, although some states do require a social work degree for this position (Bern-Klug 2008 ). Half the nursing home social services directors in the country have earned a degree in social work (Bern-Klug et al. 2009 ). Nursing homes are challenged to recruit and retain staff members at all levels. The median annual turn-over rate for direct care staff and for registered nurses in 2012 was 50% (American Health Care Association 2013 ). There are no comparable data on social work turn-over.

Although the percentage of older Americans who reside in a nursing home on any given day continues to decline, in 2014, there were 1.4 million people living in a nursing home. While the age structure of nursing home residents continues to be dominated by people over the age of 75, who account for 68% of all residents, the number of persons younger than age 65 continues to increase slightly and is now 15.5%. People age 95 and older comprised 8% of all residents in 2014 (CMS 2015 ).

Two thirds of nursing home residents were women, and the race and ethnicity of the vast majority of residents (78%) were classified as non-Hispanic White (CMS 2015 ). The functional status and daily needs of residents vary widely. While about 20% have no limitations in activities of daily living, two thirds have four or more Activities of Daily Living (ADL) limitations (CMS 2015 ). Cognitive impairment is common among nursing home residents. One quarter of residents have moderate cognitive impairment and 36% are severely cognitively impaired. In other words, 61% of US nursing home residents have moderate or severe cognitive impairment (CMS 2015 ).

In addition to adjusting to the loss of physical and cognitive function, residents must adjust to other losses such as the loss of privacy and loss of former social relationships. Some residents also experience discrimination on the basis of their age (ageism), their sex (sexism), their disability (ableism), their sexual identity (heterosexism), and/or their religious or ethnic status. The concept of “intersectionality” takes into account the ways in which one person who belongs to multiple marginalized groups may experience compounded discrimination (Crenshaw 1993 ), which is a violation of federal resident rights and human rights. Social workers should take an active role in working with fellow staff members to assess organizational policies and procedures that may be inadvertently perpetuating discriminatory treatment of residents, especially those from marginalized groups.

Federal Nursing Home Resident Rights

In the USA, nursing homes are regulated by a combination of federal and state laws which provide nursing home residents with rights and protections. The Nursing Home Reform Act of 1987 specified that Medicare and/or Medicaid certified nursing homes must protect and promote residents’ rights. Examples of protected rights include the right to be treated with respect, to participate in activities, to be free from discrimination, to be free from abuse and neglect, to have access to proper medical care, and to access to social services ( See Table 1 ). In many nursing homes, the responsibility for educating residents, families, and staff about resident rights is a core responsibility of the social worker.

The National Association of Social Workers Code of Ethics

Social work practice in the USA is guided by the National Association of Social Workers (NASW) Code of Ethics. This code includes guidance and expectations for how social workers should conduct themselves towards clients, colleagues, employers, the social work profession, and to the broader society. A key point in the Code of Ethics is the framework that “the mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty” (NASW 2008 ). Nursing home residents are considered physically, cognitively, and often socially vulnerable, because of diminished physical and/or cognitive capacity. The Code of Ethics consists of broad ethical principles ( See Table 1 ) that are “based on social work’s core values of service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence” (NASW 2008 ). Ethical standards further define these principles as they relate to different areas of social work practice. Ethical standards are featured on Table 1 , relevant examples include supporting client self-determination, appreciating cultural competency and social diversity, avoiding derogatory language, taking reasonable safeguards when acting on behalf of clients who lack decisional capacity, reporting unethical and incompetent behavior of colleagues, and addressing personal problems such as psychosocial distress, legal problems, substance abuse, or mental health difficulties that interfere with job performance (NASW 2008 ).

It is important to underscore that not all social work challenges are ethical issues; some are uncomfortable or complicated interpersonally, or involve a high degree of conflict, but do not involve any of the standards. On the other hand, social workers often encounter situations in which more than one ethical standard applies and in some cases, the potential remedies are at odds; these situations are ethical dilemmas. Sometimes the solution involves choosing the least harmful of several less than optimal outcomes. The NASW Code of Ethics does not prioritize elements of the Code. The Code “cannot resolve all ethical issues or disputes or capture the richness and complexity involved in striving to make responsible choices within a moral community. Rather, a code of ethics sets forth values, ethical principles, and ethical standards to which professionals aspire and by which their actions can be judged” (NASW 2008 ).

Human rights author and social worker, Elisabeth Reichert ( 2003 ), commenting on the NASW Code of Ethics, observed that in the USA, social workers seem to be more focused on social justice than on human rights. She encourages US social workers to embrace a human rights approach because “human rights encompass a more comprehensive set of guidelines for the social work profession” (p. 7).

Human Rights and the United Nations

Human rights are “norms that help to protect all people everywhere from severe political, legal, and social abuses” (Nickel 2014 , p. 1). In the Stanford Encyclopedia of Philosophy , Nickel ( 2014 ) identifies four defining features of human rights: (1) human rights are rights which impose a duty on others to respect; (2) human rights are plural and people or nations should not pick and choose among the rights to be honored; all human rights are important; (3) human rights are universal and apply to all persons; and (4) human rights have high priority and (in most cases) their violation represents a grave injustice. One of the most frequently cited collection of human rights comes from the United Nations.

The United Nations was founded in 1945 at the conclusion of World War II by 51 member nations who wanted to unify to prevent the atrocities that occurred during wartime by “developing friendly relations among nations and promoting social progress, better living standards, and human rights (United Nations, 2015 ).” The following quote is from a United Nations Educational, Scientific, and Cultural Organization (UNESCO) resource:

Human beings are born equal in dignity and rights. These are moral claims that are inalienable and inherent in all human individuals by virtue of their humanity alone. These claims are articulated and formulated in what today we call human rights, and have been translated into legal rights, established according to the law-creating processes of societies, both on the national and international level. The basis of these legal rights is the consent of the governed, that is the consent of the subjects of the rights (Levin 2012 , page 19).

The Universal Declaration of Human Rights of the United Nations defines human rights practices agreed upon by member nations. The Universal Declaration of Human Rights was adopted by this body in 1948 to establish the foundations for acceptable practices to promote peace and security. The preamble of the Declaration outlines the basic principle as respecting the “inherent dignity and of the equal and inalienable rights of all members of the human family [as] the foundation of freedom, justice, and peace in the world” (United Nations 1948 ).

The Declaration consists of 30 articles that establish parameters for social and human rights to which all people should be entitled. As a member nation of the United Nations, social workers in the USA should be concerned with upholding these principles in their practices, including in nursing homes. While many of these relate to government’s responsibility to an individual, “reframing a social problem like domestic violence, poverty, or discrimination into a human rights issue also creates an international context in which to combat the social problems (Reichert 2011 , p. 218).”

In order for the UN Universal Declaration of Human Rights to be more than a list of aspirations, countries must commit to accepting and enforcing them. One way to do so is to incorporate them into laws. In the USA, the Social Security Act is a law that includes language about the rights of nursing home residents and other responsibilities of nursing homes that wish to receive payments through Medicare health insurance (Title 18 of the Social Security Act) for older adults and persons with disabilities and Medicaid (Title 19) for persons who have limited financial resources to access health care. Because many long-term nursing home residents spend their last months or years of their lives within the nursing home, the home becomes their world. If they are to experience human rights, they will do so within the context of the nursing home setting.

Human Rights Issue 1: Substance Use and Abuse Among Staff and Families

The first issue we will explore within the context of resident rights, human rights, and the NASW Code of Ethics is substance use and abuse among nursing home staff and the families of nursing home residents. Protected Human Rights include provisions in the social, civil, cultural, economic, and political domains (Office of the United Nations High Commissioner for Human Rights 2008 ). Despite this, examinations of human rights violations typically focus on violations of civil and political rights by governments and in war times and exclude consideration of social, economic, and cultural rights. The United Nations declarations avow that governments must respect, protect, and fulfill all human rights. They define these terms as follows: Respect means to “refrain from interfering with the enjoyment of the right”; Protect means to “prevent others from interfering with the enjoyment of the right”; and Fulfill means to “adopt appropriate measures towards the full realization of the right (Office of the United Nations High Commissioner for Human Rights 2008 , pp. 11).”

As health care organizations that accept state and federal funds, nursing homes that accept Medicare and Medicaid are agents of the government and thus are also responsible to respect, protect, and fulfill human rights. The following section demonstrates how substance use by workers and family members in nursing homes fails to respect and protect the human rights of the individuals who reside in those settings.

Substance use that threatens the human rights of nursing home residents can take many forms. In this section, we will consider substance use and abuse among nursing home staff members and among those who visit nursing home residents, particularly family members. Substance use in this section will be used in a broad and encompassing way and refers to all substances with the potential to impair job performance or interpersonal interactions, such as alcohol, marijuana, cocaine, heroin, and prescription drugs used for other than intended purposes or by someone other than for whom they were prescribed.

Nurses and nursing assistants make up the largest group of employees in nursing homes and the ones with the most patient contact. Nurses are not the only ones in a long-term care setting that could have a substance use problem; however, most research has addressed the nursing staff population because of their central role in patient care. Substance abuse among nurses has long been recognized as a significant problem. It was addressed by the American Nurses’ Association starting in the 1980’s. They recognized that impaired functioning among nurses from alcohol or drug misuse had the potential to interfere with professional judgment and the delivery of safe and quality care (West 2002 ).

The Universal Declaration of Human Rights states “Everyone has the right to life, liberty, and security of person” (United Nations 1948 ). Being cared for by a staff member with a substance use problem puts this human right in jeopardy. A resident whose nurse is working under the influence is at increased risk for receiving unsafe care and medication errors. There is also an increased risk of elder abuse associated with caregivers’ substance abuse (National Center on Elder Abuse 2005 ). If the drugs are procured from the workplace, there is the additional threat that patients are being under medicated or that administration records are being falsified to cover the missing medications (Kunyk & Austin 2012 ).

Nurses have many risk factors for the development of substance use problems and many of those risk factors are structural barriers that put nurses with increased potential for having their own human rights violated. Human rights violations include the risk for attack or injury during work both through interpersonal violence and the physical demands of the work, which may be magnified by overwork from double shifts, short staffing, and scheduling difficulties. In 2001, the US Department of Justice found that the average non-fatal violent crime rate for nurses was nearly double that for all other occupations, 21.9 per 1000 nurses and 12.6 per 1000 other workers, respectively. Nurses or nursing assistants received 48% of all non-fatal violent workplace injuries (Strickler, 2013 ). These numbers do not include injuries related to caregiving, such as back and neck injuries from lifting patients. Having their human rights violated increases nurses’ risks of developing substance use disorders. Individual level factors such as low self-esteem, depression, self-centeredness, parental drinking, shyness, physical illnesses, dependent personality, and learning problems exacerbate these risks (West 2002 ).

Staff members who know about the substance abuse problem of a co-worker may be reluctant to report that issue because they believe the individual may lose his or her job (Kunyk & Austin 2012 ). The issue of job and licensure loss is complicated. The National Nurses Society on Addictions (NNSA) and the American Nurses Association (ANA) have recommended that state nursing boards adopt non-punitive, rehabilitative approaches for nurses with addictions, yet some state boards are reluctant to take this approach due to their duty to protect the public (Monroe et al. 2008 ). Unfortunately, there are real dangers to patients when a nurse or other staff member operates under the influence. In taking a human rights approach, the rights of both should be protected and the rights of residents are not protected by staying silent.

The NASW Code of Ethics establishes responsibilities that the social worker has to colleagues. In cases where social workers have direct knowledge of a colleague misusing substances in a way that interferes with competent practice, the social worker should first consider the feasibility of addressing the concern with the colleague directly and assisting the colleague in taking remedial action (NASW 2008 ). “This is an important first step-in some situations, the colleague may have a reasonable explanation for the behavior in question (Elpers & Murray, 2017 page 6).” If the colleague continues to practice while impaired, the social worker should use appropriate organizational and licensing channels to address the problem. If the social worker is the employee with a substance abuse issue, he or she should “seek immediate consultation and take appropriate remedial action by seeking professional help, adjusting in workload, terminating practice, or taking any other steps necessary to protect clients and others (Elpers & Murray, 2017 , page 6).”

Family Visitors

Substance use and abuse among family members who visit the nursing home also increases a nursing home resident’s risk of having their resident and human rights violated. There are several tenets of human rights relevant here. The first relevant human rights principle is that all human beings are born free and equal in dignity and rights and are endowed with reason and conscience and should act towards one another in a spirit of brotherhood (United Nations 1948 ). When a family member arrives at a nursing home intoxicated, the resident’s dignity may be violated. What would have been a private matter when the resident was in the community becomes visible to other residents and caregivers. A case of this occurred when Mrs. Green’s son arrived late at night, smelling like alcohol, asking to see his mother. The staff member who answered the door was reluctant to let him in, but his behavior seemed well-controlled, maybe a little loud for the hour, but otherwise appropriate. Following facility policy, she admitted Mrs. Green’s son and asked him to wait in the lobby while she spoke to his mother, as both his mother and her roommate were in bed. Mrs. Green really did not want to visit with her son at that hour, but knowing his problems with alcohol use, feared that if she did not, her son would become loud and belligerent with staff and potentially wake other residents. In this case, Mrs. Green made a choice to visit with her son and acted towards him in brotherhood. But were her human rights protected? She was forced by circumstances to make a less-than-free choice to protect her own dignity. What else could the staff member have done?

If the intoxicated visitor is behaving inappropriately or disruptively, staff members are put into the position of potentially having to restrict visitation to protect the safety of the resident being visited, roommates, and other residents. In this way, staff is able to protect residents’ human right to “life, liberty, and security of person (United Nations 1948 ).” However, the criteria staff use must be clear to avoid violating the human right that says, “No one shall be subjected to arbitrary interference with his privacy, family, home or correspondence, nor to attacks upon his honour and reputation (United Nations 1948 ).” This gray area between ensuring safety and interfering inappropriately is difficult to negotiate.

The protection of safety extends to the very substances used by visitors and residents with substance use problems. Visitors are the most common source of illicit substances including alcohol and medications for nursing home residents (Stefanacci, Lester, Kohen, & Feuerman, 2009 ). Since nursing homes are tasked with ensuring safety of residents, they must be aware of any substances brought into the home. Some states provide clear criteria to permit facilities to restrict visitation by visitors who are disruptive or who bring drugs, drug paraphernalia, and weapons to the facility (Benner 2004 ), but many do not. Even with support from state regulation, restricting visitation can still result in human rights violations. As was stated earlier, human rights were outlined by the United Nations to protect individuals from, among other things, legal abuses. The Declaration specifically states that everyone is entitled to all the rights and freedoms set forth without distinction of any kind (United Nations 1948 ).

Human Rights Issue 2: Resident-to-resident Aggression and Other Antagonistic Behaviors

The second issue we will explore in the context of resident rights, human rights, and the NASW Code of Ethics is the issue of aggression and conflict between nursing home residents. Resident rights and human rights issues can arise in nursing home residents’ interactions with one another and staff members’ responses to those interactions. Although resident interactions may be supportive and comforting (Bonifas et al. 2014 ), much of the literature focuses on negative exchanges such as resident-to-resident aggression (Bonifas 2015 ; Rosen et al. 2007 ; Rosen et al. 2008 ; Shinoda-Tagawa et al. 2004 ) and other antagonistic behaviors including peer bullying (Bonifas 2016 ). This section will address ethical dilemmas associated with balancing the human rights of both aggressors and the recipients of aggression in long-term care facilities. First, definitions and examples of the types of aggressive interactions discussed in this section are presented to provide a context for the reader, followed by examples that illustrate dilemmas and possible solutions.

Resident-to-resident aggression is defined as “negative and aggressive physical, sexual, or verbal interactions between long-term care residents that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient” (Rosen et al. 2007 , p. 78). Examples of such behaviors include hitting, kicking, pinching, individually directed use of profanity, and unwanted intimate touch. Peer bullying is a specific form of resident-to-resident aggression that includes “intentional repetitive aggressive behavior involving an imbalance of power or strength (Hazelden Foundation 2011 , p. 1)” as well as the experience of “persistent negative interpersonal behavior (Rayner & Keashly 2005 , p. 271)” that is directed at a specific individual or a group of individuals. Peer bullying among older adults does not typically involve physical aggression. The most common type of victimization among older adults is relational aggression (Trompetter et al. 2011 ), defined as non-physical aggression intended to hinder the formation of peer relationships and social connections (Hawker & Boulton 2000 ). Such behaviors include gossiping, name-calling, excluding, and shunning. Individuals who engage in relational aggression tend to be cognitively intact and struggling with loss of social identity (Bonifas 2016 ); whereas non-relational aggression tends to occur in the context of dementia, often in response to a perceived threat (Lachs et al. 2007 ).

Both physical aggression and relational aggression contribute to negative outcomes for the recipient. The targets of peer bullying report experiencing more social isolation, increased anxiety, and exacerbation of existing mental health conditions (Bonifas 2016 ). Physical aggression contributes to physical injury such as fractures (Shinoda-Tagawa et al. 2004 ), functional decline, depression, anxiety (Rosen et al. 2007 ), and post-traumatic stress disorder (Burgess et al. 2005 ). However, it is easy to overlook that aggressors can also experience negative outcomes. For example, they may not be able to live in their facility of choice (Teaster et al. 2007 ) or may receive high doses of psychotropic medication with detrimental effects such as over-sedation (Malone et al. 1993 ). Striving to strike a balance between residents on each side of the negative interaction creates human rights related ethical dilemmas in nursing home settings, as described below. Incidents involving physical aggression are addressed first.

Physical Aggression

The Universal Declaration of Human Rights indicates that everyone has the right to life, liberty, and security of person. Similarly, the NASW Code of Ethics requires social workers to respect the inherent dignity and worth of all persons. Living in an environment where physical aggression occurs jeopardizes these rights. In conjunction with both the Declaration and the Code of Ethics, federal nursing home regulations stipulate that facility staff must work diligently to prevent residents from experiencing any type of abuse, including physical aggression by other residents (Centers for Medicare and Medicaid Services (CMS) 2016 ). Thus, it would appear straightforward that the rights of the recipients of aggression have preeminence over the rights of aggressor.

However, the nursing home also has a responsibility to protect the rights of the aggressor. “Security of person” implies not being unnecessarily uprooted from one’s living environment, and being treated with “dignity and worth” involves assessing and meeting underlying needs that contribute to aggressive behavior in persons with dementia who are also vulnerable. Balancing human rights from the perspectives of both aggressors and recipients of aggression can lead to ethical challenges; a case example may illustrate potential dilemmas more concretely. Consider the following real-life scenario:

During a busy shift change on a nursing home special care unit for individuals with dementia that does not permit mobility equipment for safety reasons, Mr. Brown, a resident with a history of physical aggression, grabbed a cane leaning against the wall in his double room and held it down across his roommate’s throat while the roommate was resting in bed. It was unclear how long the roommate was pinned that way when staff found them when change of shift tasks, which took place in an area that hindered resident supervision, were completed. Mr. Brown was discharged to a psychiatric facility shortly thereafter and not allowed readmission to the facility, an environment in which he had lived for two years and he would have preferred to remain.

The roommate in the above situation was understandably distressed and experienced psychological harm from the experience in the moment, suggesting immediate discharge of Mr. Brown was necessary to promote the roommate’s safety and the safety of other residents on the unit. However, the roommate, who also had dementia, did not recall the incident the next day and did not appear distressed. It was difficult to determine if lasting harm occurred or if his emotional state would have been different if he had the visual cue of Mr. Brown’s presence.

At the same time, emphasizing the other residents’ right to safety may have contributed to neglect of Mr. Brown’s human rights, especially those related to security of person, dignity, and worth. Federal regulations address this point. In addition to requiring facility staff to prevent resident abuse, they require a comprehensive assessment of problematic resident behaviors to determine associated triggers, identify potentially unmet needs, and provide appropriate least-restrictive interventions to minimize re-occurrence (CMS 2016 ). These requirements may not have been met in Mr. Brown’s situation. Facility staff may have unknowingly contributed to his aggressive behavior, thus he lost his preferred home for posing a potentially avoidable safety risk.

Similarly, facility processes and procedures need to be evaluated for their contributions to rights violations. For example, on a unit that did not allow adaptive equipment, how did Mr. Brown have access to a cane to use as a weapon? Why were shift change tasks organized in such a way that staff were not able to effectively supervise residents’ interactions? Did something rectifiable trigger Mr. Brown’s behavior; did he feel threatened by his roommate in some way? Could the two men have been separated and Mr. Brown redirected with meaningful activity while room reassignments were arranged? Was there an underlying medical need contributing to his aggression that could have been identified and treated in the facility? Addressing such issues may lead to less restrictive strategies to better balance the safety needs of other residents with Mr. Brown’s needs for environmental interventions to minimize behavioral symptoms.

However, a conundrum still exists. It is not always easy to identify factors triggering aggressive behavior and even when triggers are identified, it may take some trial and error to discover which interventions effectively prevent behaviors from reoccurring. In the meantime, the safety of other residents is at risk. This situation raises the question, how long and how many interventions must facility staff try before determining relocation is the best option? If it is difficult to identify effective interventions, how can we be sure that it is truly the acuity of the resident’s underlying condition that is leading to physical aggression rather than facility staff’s lack of knowledge of behavioral management? These questions highlight the complex ethical dilemmas that can arise in protecting all residents’ human rights.

The NASW Code of Ethics stipulates that social workers be cognizant of their dual responsibility to clients and to the broader society and seek to resolve conflicts between clients’ interests and the broader society’s in a socially responsible manner. Residents who are aggressive towards peers do hinder the safety of others, but their aggressive behavior may be prevented through comprehensive assessment and individually tailored interventions. This requires effectively balancing human rights of all residents. Recently revised federal regulations strengthen requirements for staff training related to managing resident behaviors, especially those associated with dementia, and limit the potential for residents who are hospitalized, like Mr. Brown, to be denied readmission (The National Consumer Voice for Quality Long-term Care n.d. ).

Relational Aggression

The Universal Declaration of Human Rights Article 19 states that “everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive, and impart information and ideas through any media and regardless of frontiers.” Yet what are the implications of this right when long-term care residents’ opinions and related sharing involves gossiping and spreading malicious rumors about one another, calling one another derogatory names, or making racial slurs or negative comments about another resident’s sexual orientation? The NASW Code of Ethics provides further guidance, stating “social workers must respect the inherent dignity and worth of the person … [and] promote clients’ socially responsible self-determination.” The phrase socially responsible self-determination is key to addressing ethical dilemmas that arise in the context of relational aggression because gossiping, rumor spreading, naming calling, and other antagonistic behaviors are not socially responsible. Let us consider an example to better understand inherent issues.

Throughout her life, Ms. Anderson has not been around many people of color and is uncomfortable with them, holding generalized negative views of individuals with darker skin. She was socialized by her parents not to associate with people from certain ethnic groups and feels that some communities of color are very different from her. She tells other residents that Ms. James, a woman with dark skin, is a thief and actively encourages them to exclude her from group activities. Staff witness several residents telling Ms. James she cannot play bingo with them because she might steal the prizes although Ms. James has never stolen anything.

In this scenario, Ms. James is being maligned and excluded from activity pursuits of interest based on her skin color. The treatment she is receiving results in a hostile and potentially dangerous environment for her and is a violation of her human rights. Such statements cannot be tolerated because of the negative effect on Ms. James and on other residents who are witnesses. Typical responses to this situation might focus on engaging in advocacy on her behalf and providing emotional support, but how else could facility staff effectively protect her rights? One approach might be to set limits with Ms. Anderson, informing her that it is unacceptable to engage in rumor spreading or promote exclusion of individuals from certain groups. The care plan would include interventions to manage her intolerant behaviors. Although she has the right to her own opinion and values, she does not have the right to encourage discrimination against another resident.

Such an approach addresses the problem behaviors but it overlooks some of Ms. Anderson’s underlying needs. The care plan could be strengthened to better promote her human rights by acknowledging her life history of not interacting with persons of color and thus being uncomfortable. While social workers who value diversity may find it difficult to appreciate such a stance, beginning where the client is, is crucial. Thus, including opportunities for her to share distressed feelings associated with living in an environment that is not entirely comfortable and having those concerns validated without judgment could help assure that Ms. Anderson’s needs are also met. Such an intervention over time may result in less discomfort with ethnic differences and create opportunities as trust is built to include interventions that help her see similarities across diverse groups and cope more effectively with perceived differences.

Implications for Social Work Practice

Nursing homes are group settings providing care to vulnerable people, often under difficult circumstances. Difficulties can be related to inadequate resources including inadequate numbers of well-prepared staff at all levels of the facility. Difficulties can also arise between residents and families, staff and families, and residents and residents. These interpersonal challenges often involve the social worker. Having a firm grasp of resident rights within the broader context of human rights and having the benefit of the NASW Code of Ethics to inform social work conduct can enhance the social worker’s ability to understand, assess, and address the challenges in ways that are respectful and fair. Nursing home social workers play an important role in educating residents, families, and fellow staff members about resident rights. By understanding the overlap between US federal resident rights and the broader UN human rights, social workers are better able to frame some of the challenges encountered by residents as human rights issues.

While it is essential for nursing home social workers to work with individual residents to advocate for the protection of their human rights, it is also critical that social workers strive to improve the resident experience by making improvements across multiple system levels. This can include working with groups of residents, families, and groups of families to establish new and evaluate existing organizational policies and procedures to support the human rights of all residents, with particular emphasis on the most vulnerable, those who are cognitively impaired, and those who are marginalized by society. Social workers with nursing home experience are also needed to advocate for laws that serve the needs of residents, families, and staff members.

New federal nursing home regulations were issued in Federal Register ( 2016 ) and are scheduled to be phased into practice over the next 5 years (Federal Register 2016 ). These new regulations support a more person-centered environment in nursing homes and call for additional staff training in areas such as trauma-informed care and cultural competence. These and other topics can be framed as human rights and resident rights issues, to underscore the inherent dignity of all residents. Professionally trained social workers can bring their knowledge of resident rights, human rights, and ethical decision-making, to other team members in the organization for the benefit of residents and the organization as a whole.

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Kusmaul, N., Bern-Klug, M. & Bonifas, R. Ethical Issues in Long-term Care: A Human Rights Perspective. J. Hum. Rights Soc. Work 2 , 86–97 (2017). https://doi.org/10.1007/s41134-017-0035-2

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Published : 17 August 2017

Issue Date : September 2017

DOI : https://doi.org/10.1007/s41134-017-0035-2

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