ASSISTED LIVING
from Caring for the Ages, August/September 2024 (https://www.caringfortheages.com/article/S1526-4114(24)00289-0/fulltext)
by Burton Korer, DNP, MSN, RN-BC, CPHQ, CADDCT
Over 800,000 individuals currently reside in assisted living communities in the United States, and this population is expected to grow by 5% annually through 2030 (U.S. Assisted Living Facility Market Size, Share & Trends Analysis Re- port, 2030 [Grand View Research, 2023]). However, as the number of individuals residing in assisted living has increased, communities are challenged to maintain the necessary workforce.
Keeping nurses has been especially difficult for assisted living communities. Assisted living nurses continually have a turnover of 40% (K.S. Gaivin, “Turnover Rates Among Assisted Living Staff Hold Steady for Most Operators: Report,” McKnight’s Senior Living, Jan. 26, 2023), which limits the ability to develop sustainable practices in workforce leadership and the oversight of care.
Burnout and Turnover
Burnout is a state of physical, emotional, and mental exhaustion caused by chronic work-related stress and is associated with unsatisfactory workload and work conditions, as well as lack of interdisciplinary collaboration, communication, and teamwork (BMC Nurs 2017;18:16:5).
Feelings of emotional detachment, cynicism, and a reduced sense of personal accomplishment characterize burnout, which can lead to physical symptoms such as fatigue, headaches, insomnia, irritability, withdrawal, and reduced job performance (Hum Resour Health 2020;18:1–17). In severe cases, burnout can also lead to depression and anxiety.
Burnout is a common issue among nurses due to the demanding nature of their jobs, and turnover has been found to be associated with burnout in nurses. In a survey of nurses 2018, 31.5% reported that burnout had contributed to their decision to leave their jobs (JAMA Netw Open 2021;4:e2036469).
A high turnover rate also can negatively impact patient care, staff morale, and organizational costs (J Am Geriatr Soc 2022;70:2508–2516). Factors known to contribute to a high turnover rate of nurses include burnout, inadequate staffing, lack of career advancement opportunities, low pay, and a toxic work environment (Health Care Manage Rev 2015;40:237–253).
Professional burnout and turnover in nurses have been studied across many settings, but there needs to be more information on nurse’s professional burnout and turnover in assisted living.
Assisted Living Nurses: Navigating Complexity
Caring for older adults in assisted living is notable in part due to the growing needs of a population with multiple chronic diseases. Over a quarter of Americans live with two or more chronic illnesses, and the risk increases with age (Prev Chronic Dis 2020;17:E106). In assisted living, 43% of residents have Alzheimer’s disease or dementia (“Facts & Figures,” AHCA/NCAL, 2022), and 50% of residents may be exposed to polypharmacy (Consult Pharm 2018;33:321–330). The risk of falls in this frail population is also increased, and the use of mobility aides such as walkers and wheelchairs is more common than in the past.
Accessing health care for these residents requires coordination with a complex health care system driven by insurance payers and health care provid- ers. Assisted living nurses also practice under state-specific regulations and individual organizational policies. Assisted living nurses, in part, care for their residents by coordinating care between their community resources and multiple external providers — they are at the forefront in maintaining standards of care while also considering the needs of the consumer and the viability of the business model put forth by their organizations.
As a result, nursing practice in assisted living continues to evolve as the workforce seeks to deliver care in their communities as well as work within the complexity of the health system. Complexity theory, which seeks to understand patterns of interactions that may exist between system elements at different system levels (Int J Qual Methods 2018;17:1–10), may be a valuable framework for understanding the adaptation of practices to meet the needs of resi- dents in assisted living.
The interconnectedness of indepen- dent agents, the emergence of new behaviors, and the adaptation of subsystems to better align with the larger health care systems are all concepts from complexity theory. Assisted living nurses who understand the complexity of their environment may be more prepared to coordinate the delivery of care from multiple providers with less professional burnout and turnover.
The Systems Model of Clinician Burnout and Well-being
The National Academies of Sciences, Engineering, and Medicine published a consensus report that outlines the Systems Model of Clinician Burnout and Professional Well-being (Taking Action Against Clinician Burnout: A Systems Approach to Professional Well- Being [National Academies Press, 2019]). This model incorporates elements of complexity theory and identifies that “learning and continuous improvement processes” are “necessary for identifying, evaluating, and implementing effective improve- ments at all levels” to reduce clinician burnout and promote professional well-being.
The model describes three system levels that interact to influence each other and other work system factors.
- Frontline care delivery level. At this level, interactions occur “among the care team, including clinicians, learners (i.e., trainees and students), patients and families, and support staff.”
- Health care organization level. This level “broadly applies to all types of care-providing entities and is composed of numerous elements, including organizational culture, payment and reward systems, the management of human capital/hu- man resources, leadership and man- agement style, and organizational policies.”
- External environment level. In this level, the political, market, profes- sional, and societal factors “[contain] opportunities and constraints that influence decisions and actions at the health care organization level and the work done by clinicians at the frontline care delivery level.”
Actions at the three system levels impact how individuals experience work system factors, such as job demands and resources. These complex interactions impact clinician burnout and well-being, and they are further mediated by individ- ual factors, including personality, coping strategies, resilience, and social support.
A “chronic imbalance” between what a job demands and the resources available can impact well-being and lead to clinician burnout. For instance, when job demands remain chronically high (including excessive workload, inadequate staffing, administrative burden, and poor workflow) and job resources are low (including a lack of meaning and purpose at work, poor organizational culture, and limited job control and flexibility), an individual is more likely to eventually experience burnout. (Readers can refer to Table S-3 in the report to see other factors.)
Organization-Focused Interventions
The highly refined Systems Model of Clinician Burnout and Professional Well-being may provide the necessary precision to identify interventions that can address the specific burnout factors in the unstable system of assisted living today. Evidence does exist that organizations can mitigate burnout and can become a powerful determinant in reducing clinician burnout. The evidence further supports that strategies focused on individuals are less effective than those focused on organizations in addressing clinician burnout.
An example of an organization-focused intervention is to reduce administrative burden by ensuring that the necessary resources of personnel and technology are committed to maintaining compliance with regulations, policies, and standards. The model provides guidelines for designing, implementing, and sustaining systems in organizations to address burnout, focusing on (1) values, system approach, and leadership; (2) work system redesign; and (3) implementation.
This model may be valuable for studying our complex work environment. Addressing the turnover of assisted living nurses is vital to the mission of organizations providing care to older adults — and understanding the factors contributing to burnout and then promoting effective adaptation in the workforce can help address the impact of burnout on turnover.
Dr. Korer is a registered nurse with over thirty years of experience in care transitions and coordination of care, with a focus on pharmacy and nursing collaboration. He is currently earning a phD in nursing at George Washington university with an area of research on systems theory in health care.