Staffing shortages are the primary challenge facing directors of nursing services (DNSs), according to 75 percent of the DNS respondents in the 2019 AADNS Director of Nursing Services Work Study and Salary Report. In addition, 63 percent reported not having enough direct-care staff to adequately care for patients.
DNSs have traditionally been wary of using agency staff due to survey and quality-of-care concerns (e.g., studies have shown a clinically significant decrease in quality at facilities that use higher levels of agency staff). However, temporary certified nursing assistants (CNAs) can be a valuable resource to fill vacancies or open spots on the schedule so that a facility can meet patient care needs, according to Jill Snow, MBA, BSN, RN-BC, CHC, senior vice president of clinical operations at Ethica Health and Retirement Communities in Gray, GA, and vice chair of the AADNS Board of Directors.
Risk mitigation can help DNSs successfully alleviate potential concerns, suggests Snow. “Unfortunately, sometimes DNSs are so busy that it’s difficult to pay attention to this vital aspect of working with temporary agencies. But you can’t afford to skip these steps in order to mitigate the facility’s risk.”
The following four steps can help DNSs achieve some consistency around the use of temporary CNAs while they work to recruit and retain their own staff:
Get proof of background checks and other contract requirements
DNSs should make sure that the facility’s contract with the temporary agency is both in place and thorough before CNAs are actually needed, says Snow. Contract requirements for agency staff usage should begin with background checks.
“The temporary agency is obligated to do background checks and provide you with evidence of not only what the federal government requires, but also what the state government requires if it’s more intensive than the federal government’s requirements,” says Snow. “Evidence of compliance with such requirements should be provided to the facility before a CNA starts work.”
Assuming without evidence that the temporary agency is fulfilling its contractual requirements related to background checks can cause significant headaches for providers because the burden of responsibility is the facility’s once the CNA begins working, says Snow. “For example, if an agency sends a CNA who does not have an appropriate background check—even though your contract with the temporary agency says it should have been done—and there is an allegation of harm, you could spend weeks working through regulatory consequences, including steep fines.”
To bring temporary CNAs in the door, “you should have evidence of all of the information you would normally have for a CNA you hired yourself,” says Snow. “For example, in addition to evidence of background checks, you should obtain evidence of the CNA’s education on abuse and other training requirements. You’re not maintaining temporary CNA education records since the agency is their employer. However, you need to make sure the education has been done. Obtaining this information beforehand protects your building and your patients.”
Don’t skip orientation
Whether temporary CNAs receive an extensive orientation or a brief orientation “depends on the mission of the organization using the temporary staffing,” says Snow. “However, you shouldn’t place a temporary CNA on the floor without some basic orientation information.”
At a very minimum, temporary CNAs need to have education around the basics of working in the specific building, such as “how to evacuate in the event of an emergency, schedules, expectations, and who to call when there is a problem,” points out Snow.
“Other examples include pertinent documentation requirements,” she explains. “If your facility has an electronic health record (EHR), they need to know how to use that EHR. Or, if you have ‘pen-and-paper’ documentation tools, they need to know how to use those. They also have to know what they must document. You should narrow it down to those items that must be documented—and not try to cast too wide a net.”
Establish preferred providers
When using temporary CNAs, it’s important to lessen the impact on ongoing team-building and quality improvement initiatives inside the facility, says Snow. “One way to limit disruptions and have some stability in a very unstable world is to work with as few temporary agencies as possible, similar to designating preferred providers.”
Finding the right preferred providers is about relationships, advises Snow. “You can look up a temporary agency at the Better Business Bureau, but it’s more about dependability and the strength of their staff—factors that are more obvious the closer your relationship is. Do they have a good mission-driven approach? That sounds idealistic, but some agencies don’t care, and some care a lot. You need to know what you want, and then seek out agencies with the same value system. The bigger ones are not always the better ones.”
Preferred providers often may be willing to conduct expanded training, adds Snow. “For example, if agencies who are preferred providers know your procedures related to clocking in and out for Payroll-Based Journal, they may teach their CNA staff what those procedures are before they ever get to you.”
Practice consistent staffing
Instilling a culture of person-centered care—and of excellence—can be difficult if temporary CNAs work in the facility for a single eight-hour shift, points out Snow. “If a temporary CNA comes in for eight hours and then you never see them again, they may not be as invested in what’s happening in your facility. You may not be able to elicit the caring response you need, as there is no long-term ‘ownership’ of the patients in their care.”
So even though the up-front cost may be higher, DNSs should consider contracting temporary CNAs for an extended period of time, she suggests. “For example, after reviewing your schedule, you might negotiate with your temporary agency to secure staff for eight-, 10-, or 12-week assignments upfront.”
Extended assignments allow DNSs to enculturate temporary CNAs to the facility and its mission, says Snow. “They see your patients, they know your patients, and they know your expectations. You will be able to establish the stronger commitment to have those temporary CNAs deliver really good care at the bedside and then document it well.”
Editor’s note: Do you need assistance achieving staff stability or consistent staffing? Review the National Nursing Home Quality Improvement Campaign’s Staff Stability page, which includes links to staffing toolkits developed by the Centers for Medicare & Medicaid Services’ Civil Money Penalty Reinvestment Program, and the campaign’s Consistent Assignment page.
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