Long Term Care Facilities - I Did the Math and It Doesn't Add Up

How many other patients does her nursing assistant have to care for? Could you get her ready for the day in 18 minutes?

Photo by [Flickr User]. (License: Creative Commons Attribution)

One simple question: On an ordinary morning, how long does it take you to do your basic morning care?
Another simple question: How long does it take you to eat your largest meal of the day?
Finally, how much time do you spend making your bed and picking up in your bedroom a day?

Let's break this down. Making the bed and picking up the room would take maybe 5 minutes if you are fast. Brushing teeth should take 2 minutes for good mouth health. Combing hair takes a minute. Taking a sponge bath would take about 5 minutes. Selecting your clothes, getting dressed, and putting on your socks and shoes would take about 5 minutes. You are looking at a minimum of 18 minutes from the time you hop out of bed until you are "ready" to go. We'll give it the benefit of the doubt, though and call it 15 minutes. Since I am feeling generous, we will say you only have to repeat this 8 times - once for every patient on your assignment. We are also assuming that every one of your patients can walk. That's not the only assumption we are making: none are men, so you don't have to account for a minimum of 10 minutes a piece to safely shave each one. None are incontinent of bowel or bladder so you don't have to struggle with getting an adult incontinent pull-up or tape-on brief on, nor do you need to completely strip and remake a soiled bed. You don't have to take the time to make sure you have cleaned up a bowel movement thoroughly. None of your imaginary patients are confused or combative with your attempts to get them ready for the day. We also assumed that it is not "bath day" for any of your patients. We've assumed that none of your patients have tubes to maneuver around and none have dressings that need to be changed before they can be dressed. None have doctors appointments to be dressed for and none need to be repositioned every two hours. If we let you out of morning report, you have managed to get all of them up, dressed, and ready for breakfast at 9am. You still need to walk or push them to the dining room, though - all 8 of them. You need to pass out meal trays and set each tray up for each patient to eat. We will say that they are capable of feeding themselves, though. None of your patients has a family member there who wants you to stop in the middle of the morning rush and go get more ice. None of your patients put their call light on while you were helping another patient get ready. No one is sick. No one needs their vital signs or their temps taken. You did not have to hunt anyone down who wandered away from their room before you could get them dressed. No one fell. Still, you should tack on an hour for breakfast service, an hour for lunch service, an hour for your 30 minute lunch and two 15 minute breaks. Bear in mind that you will have to "cover" for another nursing assistant's 8 patients for an hour while that one takes her breaks. You also need to do your care flow sheets for each of your 8 patients before the end of your shift. You are having a really good day. You are also dreaming. Five hours of your "fantasy" day is gone without you taking any time out to clarify instructions, ask the nurse for more information about something, try to find a missing shoe, help a lost visitor, answer a family member's questions, help one of your co-workers lift a heavy patient, give a delivery person directions, pass out snacks, weigh any of your patients, pass ice, or take any of your patients to activities, physical therapy, or occupational therapy.

Now let's talk about reality. It's day shift and you only have 8 patients in your dreams. You are more likely to have between 10 to 15 patients on your assignment. Half to three quarters of that number will be completely incontinent of bowel and bladder. Half will require a wheel chair or a geri-hair for mobility. You will have to snag another aid to help you lift them from bed to chair after you have struggled to put clothes on them while they are lying in the bed. A minimum of one third will be having a complete "bath day." You will have to strip those beds completely and remake them, in addition to the beds you have to completely strip and remake because of incidental soiling. Usually half of your patients will have mild to severe confusion and some of those will become combative while you are trying to dress or toilet them. Half of your patients will require repositioning every two hours to prevent bedsores. The incontinent patients will need their briefs checked and changed every two hours. At least two or three will need vital signs or temps taken. You will have to wait on the nurse to come change a dressing for at least one of your patients before you are able to get them up. Half of your patients will have to be put back down in the bed for a nap in the afternoon. Most facilities will expect you to get report when you come on duty and give report before you leave. Two to three of your patients will have to be spoon fed at each meal. You also need to pass ice to all your patients and pass snacks in the afternoon, again spoon-feeding snacks to those patients who can not feed themselves. You need to drop what you are doing to take your patients to the activity room for various activities through the day. In all likelihood, there will be several men on your assignment that need shaving.

You also will get stopped by someone every time you leave a patient's room to go to the next: a family member that wants a report, a nurse that needs help holding a patient on their side while their dressing is being changed, a visitor that needs directions, a patient that wants an ice refill, another aide that needs help lifting one of their patients, the administrator who wants you to drop everything and go to the other end of the hall because a patient is down there screaming "Help Susie, Help Susie!" Even though you know she does this at this time of day, every day and does not really need anything but a nap, the administrator is worried about appearances and is too "busy" to find that patient's assigned aide and why should she when you are so handy! This is your average "good" day in Reality Land.

A bad day is when someone starts throwing up, you get busted in the mouth or fall victim to the dreaded "pinch and twist," someone falls, the nurse needs help putting a catheter in someone, someone is having diarrhea, one patient clobbers another, a patient has an appointment or needs to be gotten ready to go to the emergency room, or a family member comes in and chews you a new one because mom is not wearing the right clothes or dad is still in bed and it's almost lunch time - and while you are getting a good "dressing down," precious time is being stolen from one of your patients. This is reality for hundreds of thousands of long term care nursing assistants day after day and year after year. Sadly many, if not most, fall into the "working poor" category - actually I should say WORKING poor.

When you go to put your loved one in a nursing home, ask specifically how many patients each nursing assistant is assigned on day shift, on evening shift and on night shift. Do not be conned about staff to patient ratios. Chances are they will try to slip dietary, housekeeping, and maintenance staff into their numbers. At the very least, they will try to give you a ratio that counts the director of nursing, assistant director of nursing, the shift supervisor (who seldom touches a patient,) and the charge nurse who is too busy passing medications and doing treatments to help much. Specifically ask about the ratio of nursing ASSISTANTS to patients, not nursing STAFF to patients. After you have that figure, you do the math. Find out what the state minimum is. If that facility is trying to ride the barest minimum number they can legally get away with, run, don't walk, to the nearest exit. Sitting on a minimum staffing regulation is clearly a sign that they have more important things to worry about than the quality of your mother's care or the well-being of their staff - namely their profit margin. As pathetic and despicable as it sounds, corporate greed is alive and well in the long term care industry.

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