INTRODUCTION

A. Addressing the lack of staffing for Alzheimer's disease patients

1. Creates many unnecessary events that are likely to happen if the staff- patient- ratio is not addressed in long term care facilities, such as nursing homes with specialty care units and assisted living facilities.

2. Currently, there are Federal and State guidelines addressing staff-ratio for all residents in long term care facilities.

3. The current laws do not address specific needs and issues concerning Alzheimer's patients.

4. The Azheimer's population is included with other residents at the facility when it comes to staffing issues.

5. Staff-patient-ratio is a very important ethical issue.

6. It has everything to do with the quality of life for these victims.

7. The mission is to change the law of staff-patient ratio in long term care facilities.

IDENTIFYING THE MAGMTUDE OF THE PROBLEM

A. The current number of Alzheimer's Disease victims is estimated at 4 million people in the United States.

B. By the year 2030, it is estimated that there will be over 14 million victims.

C. In Florida alone by tbe year 1999, more than 170,000 Floridians will have Alzheimer' s disease or some other form of severe dementia.

D. In 1992, the Office of Technology Assessment indicated that 50 percent of all nursing home admissions in the United States are diagnosed with Alzheimer's disease.

E. A popular development growing for Alzheimer's disease residents are the special care units (SCUs).

F. In 1994, Alzheimer's Association's estimated over 1500 special care units in the United States caring for over 50,000 residents. The growth is a result of family members who are unable to provide care at home.

G. As the stages progress in the disease, institutional care is most likely needed. This population is a growing proportion of long term care facilities

H. Research shows that managed facilities or units are especially designed and staffed for this population.

I. As a result of this increasing population of Alzheimer' 5 disease patients and the growing rate of special care units, there is a growing concern from family caregivers of the staff- to-patient ratio in these facilities.

I. In order to have an effective management program for dementia patients, there must be a lower staff-patient-ratio.

J. Currently, state guidelines are based strictly on anyone living in a long-term care facility. The need for the proper care of Alzheimer's disease patients is not addressed in either the state or federal regulations.

K. Laws and regulations vary ftom state to state concerning residential care.

L. Long term care facilities base their care on the medical and psychosocial models. All states vary which model they use.

M. A study conducted showed concerns for the best practices in Alzheimer's care to regulations and regulatory practices in ten states.

1. The level of actual language regarding services, training, and staffing varied widely.

2. Formats and language made it very difficult to compare facilities.

3. There is little consistency from state to state regarding goals and purposes in the residential care/assisted living area

4. Researchers addressed factors thought important to serving dementia population in residential settings.

5. Factors came from a list of items used addressed in regulations.

6. A model, 'Alzheimer's Friendly", was drafted which addressed all aspects of regulations in which states are likely to be interested.

7. "Counter to best Alzheimer practice" was used if it prevented such good practice.

8. "Silent/neutral" was used if it would allow, but did not foster best practice.

9. Results show that in Special Care Units, there were nine in the category of silent/neutral and one in the area of Alzheimer friendly practices dealing with staff/patient ratio.

10 The study found major differences between states to which regulations reflects an understanding of the large percentage of assisted living residents who suffer from cognitive impairment.

11. The Florida rankings among the ten states based on 33 elements are as follows: Alzheimer's friendly (8); Counter to best Alzheimer's practices (8)and Silent/Neutral (17). The average of all the states showed Alzheimer friendly (10.3), Counter to best Alzheimer practices (7.3) and Silent/Neutral (16.2)

ALTERNATIVE SOLUTIONS

A. To receive good quality care in longe term care facilities, Alzheimer~s patients must have the proper staff/patient ratio.

B. Increased activities for these residents are essential. A lone individual wandering, appearing confused is hardly a well planned out day for this individual.

C. Residents deserve to feel a part of their environment by doing things as long as they can independently.

D. Must be allowed to feel a sense of worth within their environment.

E. Structure is a very important part of this population's world. It is important for a caring staff member to sit or walk with the resident and to just be a friend.

F. With increased staffing in long term care facilities, there will be a decrease in stress among the residents and also the professional caregiver.

G. Coping with Alzheimer's daily living can lead to staff burnout and high turnover. Employees become discontented when they do not have enough help.

H. Dependability will decrease without sufficient staff and result in suffering for the

I. residents. It is not uncommon for employees to call in the day of work or just not call or come to work at all.

J. Support groups for the staff members are a very vital part of caring for Alzheimer's residents. It allows them to share problems and concerns about the feelings of loss due to the death of one of the residents or just being allowed to vent about a particularly bad day.

K. An increased staff/patient ratio will result in a decrease of incidents/accidents such as falls.

L. There would be less chemical or physical restraints within the environment. There would be less irritation and confusion among the residents.

SUMMARY

A. There must be a change in the regulations of staff-patient ratio in Florida and the United States in order for there to be a good, safe, quality of life environment for Alzheimer's disease victims.

B. The elderly population is increasing and the rate of Alzheimer's is on the rise as well.

C. Regulations must be addressed carefully to specifically meet the needs of Alzheimer's residents in long term facilities.

D. Quality care of these individuals will only continue to be questioned and decline.

E. Increasing staff-patient ratios will only enhance the positive effects of not only the patient, but also the professional caregiver as well.

F. Patients will receive quality care and a better life. Caregivers will also find relief from high pressures and stressful times caring for these individuals.

G. It would also be a great relief to the family caregiver knowing that when they walk away their loved one is being watched safely and being cared for properly.

H. The main issue is that no Alzheimer's patient should ever have to suffer for any reason because they are not being watched properly due to low staffing.

1. Quality of Life and Ethical Issues:

Statement:

* A good understanding of how ethics effect the care of people with Alzheimer's Disease is very important.

* All individuals deserve respect for who they are.

* Each person is unique. Caregivers must understand what is happening to a person with Alzheimer' s disease.

* They must think about what it must be like to lose their memory.

* Self-identity plays a big role with this population.

* Caring for these individuals until the very end of life is a very important ethical issue.

* They should be treated with dignity and respect.

* Without good staff-patient-ratio, it is impossible for these issues to be addressed.

*Quality of life for Alzheimer's population encumbers several issues such as Incontinence, undressing, dignity, surroundings conducive to the illness itself, and dependency on activities of daily living.

2. Increase in activities for Alzheimer' s disease residents.

Statement;

* Requires activities of living that have a meaning and a purpose.

* Encourage dependency of residents. (ie. Dressing, feeding)

* Encourage voluntary tasks such as meal preparation, clean up and light housekeeping tasks.

* The more staff available to implement activities, the more quality of life for the Alzheimer' s resident.

* Residents will wander less if given more activities to keep them occupied.

3. Stress reduction among Professional staff care givers in the Alzheimer' s disease population.

Statement:

* Coping with Alzheimer's disease residents requires more skills, patience, and understanding than other long term care facilities.

* Insufficient staffing can result in staff disillusionment and frustration which can lead to staff burnout and turnover.

* Lack of training in Alzheimer's care and a true understanding of the disease can result in inadequate care for the patient.

* By mandating an increase in staff-patient-ratio, Alzheimer's patients would be allowed to live a beffer quality of life.

4. Decrease of incidents/accidents for residents of Alzheimer' s disease residents.

Statement;

* With an increase in staff numbers, falls will decrease.

* Behavior problems are a big issue with Alzheimer's disease. Proper staffing will enable behavior problems to decrease. If a resident does not have enough to do, he/she will become agitated and confused which can lead to behavior problems.

* With an increase in staff/patient ratio, there would less physical and chemical restraints.

* With more hands on with the residents, staff members can assist them in eating that will allow them to have weight gain.

The State of Florida statutes gives the following as the minimum full time equivalent staff within a 24-hour period of time for adult congregate living facilities, also known as assisted living facilities. These ratios include residents of both cognitive and non-cognitive abilities. (Appendix B)

Residents-Minimum FTE staff

1-5 - 1

6-15 - 2

16-25 - 3

26-36 - 4

36-45 - 5

46-55 - 6

56-65 - 7

66-75 - 8

76-85 - 9

86-95 - 10

Instructions in which facilities calculate nursing staff:

1. Determine facility census: 120

2. Multiply census by .6 hours to obtain minimum total hours. 72

3. From time sheets sum licensed nurse work-hours. 90

4. Line 3 exceeds Line 2 then minimum staffing is satisfied.

Instructions in which Certified Nursing Assistants staffing is calculated:

1. Determine facility census: 120

2. Multiply census by 1.70 hours to obtain minimum total hours. 204

3. From time sheets sum CNA work-hours. 235

4. Line 3 exceeds Line 2 then minimum staffing is satisfied

The Federal mandates are also based on minimum staffing issues. The intent reads: To assure that sufficient qualified nursing staff are available on a daily basis to meet resident's needs for nursing care in a manner and in an environment which promotes each resident's physical, mental and psychosocial well-being, then enhancing their quality of life. A minimum staff is defined as licensed nurses and certified nursing assistants. The determining factor of proper staffing is sufficiency. A deficiency concerning staffing should provide examples of care deficits caused by insufficient quantity and quality of staff If inadequate staff presents a clear threat to resident care, even when adverse effects have not occurred, or there is a lack of residents reaching their highest practicable level of well-being, this will be defined as a deficiency.

Determination of nursing staffing:

* Is there adequate staff to meet direct care needs, assessments, planning, evaluation, supervision?

* Are there trends in the facility, which might be indicators of decreased quality of care as a result of insufficient staffing to meet resident needs (e.g. increases in incident reports, the infection rate, hospitalizations?

* Do work loads for direct care staff appear reasonable?

* Do residents, family, and ombudsman report insufficient staff to meet resident care?

* Are residents who are unable to call for help, checked frequently (ie. each half hour) for safety, comfort, positioning, and to offer fluids and provision of care? How does the sufficiency (numbers and categories) of nursing staff contribute to identified quality of care, resident rights, quality of life, or facility practices problems?

Facilities cannot function well without competent staff/patient ratio. Co-author of The 36 Hour Day, Nancy Mace states that specialty care units must create an environment that reduces harrnfiil stressors, but at the same time enriches a positive stimuli. The program and staff are more important than the actual physical plant. Proper staffing decreases the level of stress as the disease progresses. With efficient staffing there is an improvement in eating, sleeping, sense of humor, the formation of friendship and interpersonal exchanges which decrease wandering, agitation, the need for medications, depression) incontinence and hallucinations. The right amount of staffing enables the nurse to plan, guide and evaluate care administered by nursing assistants (McCracken, Gilster, 1991). The more severe the needs of the residents for assistance or supervision, the more staff will be needed (Noyes, 1996.)

REFERENCES

Hyde, Joan, (1996). Alzheimer's friendly assisted living regulation. The American Journal of Alzheimer's Disease, 3, 4, 6, 8.

Mzheimer's Disease Initiative Plan, The Florida Department of Elder Affairs, 1995.

Kosberg, J., Garcia, J., & Dulka, I., (1997). Ensuring the adequacy of long-term care of AD patients: Special challenges and advocacy mechanisms. The American Journal ot Mzheimer's Disease, 34.

McCracken A., Gilster S., (1991), Developing a viable residence for persons with Alzheimer's disease. The American Journal of Mzheimer's Care and Related Disorders & ~ 39, 41,42.

Noyes, Lin E., (1996). Assisted living for people with Alzheimer's disease: Strategic planning and management considerations. The American Journal of Alzheimer's Disease. 14.

(c) copyright by Melinda Ross 1998