The American Association of Nurse Assessment Coordination has released the results of its most recent nurse assessment coordinator (NAC) work study, the findings of which highlight the challenges faced by NACs in their jobs—and illustrate how such challenges may be affecting morale, job satisfaction, and even NAC turnover.
The goal of the work study, according to AANAC’s press release, was to:
· Benchmark and report average completion times for the MDS, by assessment type
· Benchmark and report compensation levels by various factors
· Benchmark and understand the time factors affecting accurate MDS assessment
· Benchmark and understand nursing home staffing practices and trends
Data was collected through a survey of AANAC members. Out of 14,700 AANAC members who received an email about participating in the survey, 693 NACs responded. To gather the most accurate data related to NACs currently working in the field, AANAC analyzed only the survey data submitted by members who currently work full-time in the role of “MDS coordinator/nurse assessment coordinator.”
“We believe this survey provides a representative sample of the NAC field, with 693 NAC respondents, a 95% confidence level, and a +/– 4% margin of error,” states the press release.
Similar studies were also conducted in the last quarter of years 2011, 2013, and 2014.
The Big Three
Although the findings of the study were many and varied, three points stuck out notably as representative of the main struggles faced by the NAC community, says Jessie McGill, RN, RAC-MT, and curriculum development specialist for AANAC.
1. The Addition of Section GG
Section GG was added on October 1, 2016, to meet requirements of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) and the Quality Reporting Program (QRP). If facility staff do not submit at least 80% of the data required to calculate the QRP measures, then the facility can face a 2% reduction in its annual payment update from Medicare.
Section GG has two main components: self-care, which added three items, and mobility, which added nine items. To complete this section, the NAC and interdisciplinary team (IDT) are to identify the resident's usual or baseline performances during the first three days of the Medicare stay. The NAC and IDT must also identify at least one goal for self-care or mobility.
AANAC found that the time frame for completing the scheduled 14-, 30-, 60-, and 90-day assessments rated similarly to the work study released in 2015. But with the 5-day assessment, NACs reported that it took them an average of 13 minutes longer to complete than it did previously.
And the only difference between the 5-day assessment and the other scheduled PPS assessments was the addition of section GG.
“So we can safely attribute the additional 13 minutes’ completion time to section GG,” says McGill.
(McGill notes that by the time the survey was issued, in February 2017, any growing pains associated with adapting to section GG should have already occurred. Thus, she says, the longer completion time is likely an accurate ongoing projection.)
“Since section GG is completed on every 5-day assessment, whether it is a new Medicare admission or a readmission,” says McGill, every 5-day assessment means “13 additional minutes for the NAC workload.”
The second part of the October 2016 changes is the addition of the Part A PPS Discharge (NPE) assessment, which also contains section GG. This is an end-of-stay assessment that must be completed anytime the Medicare resident is coming off a skilled stay and is either remaining in the facility or being discharged out of the facility. The NAC must identify the resident’s usual performance for the self-care and mobility items during the last three days of the Medicare stay to document discharge performance on the NPE.
The work study found that the completion of a stand-alone Part A PPS Discharge assessment takes an average of 30 minutes. This assessment is stand-alone only when the resident’s Medicare stay is ending and he or she will remain in the facility. When the Medicare stay is ending and the resident is discharging out of the facility the day of or one day after the end of the Medicare stay, the NPE may be combined with the OBRA Discharge assessment.
NACs reported that the OBRA Discharge assessment takes on average 35 minutes to complete. However, when it is combined with the NPE, completion time increases to 41 minutes.
Those additional minutes can quickly compound, depending on how many Medicare admissions and discharges occur in the facility.
Which leads to the second big finding from the study:
According to the work study, 76% of NACs rate their workload as “challenging” or “very challenging.”
This is potentially problematic, as it could be leading to job dissatisfaction among NACs. That’s why determining the specific factors causing the crushing workload is so crucial.
“Identifying why the workload is so challenging for NACs needs to be the first step. If you are able to reduce the workload or increase efficiency, this may help to retain NACs and improve job satisfaction,” says McGill.
McGill speculates that some of the major stressors could include:
· A shortage of staff, leading NACs to take on extra duties
· An excessive number of meetings that NACs are required to attend
· Being pulled to provide direct nursing care
· Leadership responsibilities, such as manager duty on evenings or weekends
One particularly interesting takeaway from this finding, says McGill, is that NACs with 10 or more years of experience rated the workload as more challenging than did NACs with 2 or fewer years of experience.
“We have to consider if we are adding responsibilities and non-MDS job duties to our experienced NACs because we think that they can handle more. An experienced NAC may also be a leader and mentor in the facility, which adds to the workload, while we may be protecting or reducing the workload of our new NACs as they are learning the new role,” says McGill.
And, as noted, with the addition of section GG, the issue of workload is often compounded by frequent updates to regulations.
These issues, if unaddressed, could even lead to NACs leaving the field altogether.
“I think there is a strong correlation between the changes in the regulations, the challenge of the workload, and turnover,” says McGill.
Which brings us to:
It’s no secret that there is a nationwide staffing crisis pertaining to the NAC role.
But what many may not know is that much of the turnover is taking place specifically among experienced NACs, according to the AANAC work study.
In the work study released in 2015, 56% of NACs who responded had 10 or more years of experience in the role. That decreased to 45% in 2017.
Meanwhile, in 2015, only 7% of NACs responded that they had 2 or fewer years of experience. That increased to 17% in 2017.
“The work study showed a big shift in NACs with 10-plus years of experience leaving the position, and NACs with 2 or fewer coming into the position,” says McGill. “Which brings me back to an earlier finding: Since we identified that the workload is rated as more challenging for a NAC with more experience, I think we have to ask ourselves if there is a direct correlation between the workload and turnover.”
Turnover, especially of a seasoned NAC, says McGill, can have a tremendous impact on a facility. It could potentially affect Quality Measures, Five-Star ratings, survey outcomes, and reimbursements and could have adverse effects on the residents if their care plans aren’t accurate.
McGill explains, “When a seasoned NAC resigns, we are not only losing that experience and expertise, we are losing the systems and processes that came with that experience.”
Facility leaders will need to evaluate these problems and determine the solutions that best suit their individual needs and circumstances.
But regardless of exactly what that looks like, says McGill, it starts with an open dialogue.
“One good starting point would be to confirm that there are adequate hours to meet the needs of the NAC. Identify whether you have enough time for the NAC to do the job,” says McGill.
If leadership is adding additional responsibilities to the NAC’s role, it’s important to consider what additional support can be added to the department. Maybe it’s part-time staff. Maybe there are members of other departments who can lend a hand in areas that support the MDS process.
This is especially pressing because October 2017 will bring even more changes—and more minutes added to the MDS process.
“We have to, as a profession, really look at what kind of stress this is putting on our NACs, and how we can support them through all these changes,” says McGill.
Leaders need to talk to their NACs about their workload, says McGill, and identify whatever training, education, or support is needed to help the NAC successfully perform the job and navigate changes to the MDS.
However, leadership may not know what is needed or what part of the workload the NAC finds most challenging. That’s why it’s important that NACs know they can also take the initiative: if no one else is bringing up the topic, then you can be your own advocate.
After all, this is your position, and you’re the one juggling the workload. Your facility administration doesn’t want to lose your experience and expertise.
In other words, your voice matters. So if you need something, don’t be afraid to say something.
Other Notable Points
Other significant findings from the work study include details pertaining to salary levels nationwide. Salient points include:
· NAC RNs earn an average of 10% more than LPN/LVNs.
· NACs working in an urban facility are more likely to have a higher wage than NACs in rural facilities.
· NACs working in the midwest/central U.S. are least likely to be compensated over $70,000 annually.
· NACs working in the east/southeast U.S. are most likely to exceed $71,000.
· 47% of NACs reported that they are satisfied or very satisfied with their current salary.
· 27% reported that they are dissatisfied or very dissatisfied with benefits.
· NACs reported that challenges related to stress and burnout increased as compensation increased.
· Satisfaction with salary, benefits, job security, and work/life balance also increased as compensation increased.
For those looking for comprehensive findings from the 2017 NAC work study, the final report is available here.
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