NR 669 Week 3 Setting and Role Analysis Example

Setting and Role Analysis: A 120-Bed Skilled Nursing Facility at Work and the Infection Preventionist Role as This Building Actually Runs It

Student Name

College of Nursing, Chamberlain University

NR 669: Advanced Nursing Role Immersion Part 3

Instructor Name

Month Day, Year

Setting and Role Analysis: A 120-Bed Skilled Nursing Facility at Work and the Infection Preventionist Role as This Building Actually Runs It

The Organization at Work

A 120-bed skilled nursing facility on two floors. The first floor holds a 40-bed short-stay unit for patients recovering after hospital stays, mostly after hip and knee surgery, strokes and pneumonia. The second floor holds two long-term units of 40 beds each, where most residents have dementia, need help with most daily activities and stay for months or years. On a typical weekday, 8 to 12 short-stay patients are admitted and a similar number discharged.

Staffing on day shift: one registered nurse supervisor, five floor nurses, a mix of registered and licensed practical nurses, and about fourteen certified nursing assistants. Evenings have one fewer nurse and two fewer assistants; nights have three nurses and eight assistants. Physicians and nurse practitioners come from an outside medical group, visiting twice weekly and taking calls the rest of the time. A consultant pharmacist reviews medications monthly.

What Binds It

Money: Medicare pays for short stays at a higher daily rate than Medicaid pays for long-term residents, so short-stay admissions keep the facility solvent. Hospital referrals depend on the facility's rating and on avoiding readmissions.

Regulation: the facility is surveyed annually by the state on behalf of federal regulators, and infection control is among the most frequently cited areas in nursing home surveys. The federal requirements of participation set the infection prevention and control program, the antibiotic stewardship program and the infection preventionist role (Centers for Medicare & Medicaid Services, 2016).

Staffing: a regional shortage of nurses and assistants means call-outs are covered by whoever holds a nursing license and is in the building.

These three bind the role. Survey risk makes infection control matter. Funding makes short-stay readmissions matter. Staffing shortages decide whether the role's time survives the day.

The Role as This Place Runs It

On paper: Infection Preventionist and Staff Development Coordinator, one full-time registered nurse, half time in each function. The IP completed the federal training course for nursing home infection preventionists and has 14 years of long-term care nursing.

In a working week, observed over three weeks: about 12 hours on infection prevention, mostly surveillance and the line list on Mondays and Fridays; about 16 hours on staff development, including new-hire orientation, annual competencies and CNA in-services; about 8 hours covering nursing shifts or helping on the floor; and the rest on employee health tasks, such as tuberculosis screening and vaccination records, which are not in the job description but have fallen to the role.

Calls the IP makes alone: placing a resident on transmission-based precautions; opening an outbreak investigation; deciding what goes on the line list; scheduling staff education.

Calls the IP takes elsewhere: any antibiotic decision, to the prescriber; any change in staffing to manage an outbreak, to the director of nursing; reporting to the health department, done jointly with the director of nursing.

Parts of the building the role has reason to enter: every resident unit, the laundry, the kitchen and the therapy gym, for environmental rounds; the administrator's office, for the monthly quality meeting.

Two Reporting Pictures

On paper, the IP reports to the director of nursing. In a working week, the IP answers to three people: the director of nursing for staffing and education; the administrator for survey readiness and the quality meeting; and, during outbreaks, the county health department's epidemiologist, whose requests take priority over everything else. The paper picture misses the third entirely and understates the second.

One Decision, Traced

On 22 September a short-stay resident developed diarrhea. The floor nurse called the IP, who checked the line list, saw a second resident on the same hall with loose stools two days earlier, placed both on contact precautions and asked the nurse to send stool samples for testing. The IP told the director of nursing, who added an extra assistant to that hall for the evening. The prescriber ordered testing by phone. One sample was positive for C. difficile, the other negative. The IP reported the case through the surveillance system, scheduled an environmental cleaning review with housekeeping and added a hand-washing reminder at shift report. The decision moved through four people in six hours, and the IP held it together without a meeting or a form. On a day the IP was covering a medication cart, the same decision would have waited.

How the Role Compares With the Program's Description

My program describes an advanced nursing role in infection prevention through four functions: surveillance, data analysis, education and leadership of stewardship. In this building, education is fully present, surveillance partly, analysis barely and stewardship leadership only through monthly reports. The functions the program weights most heavily are the ones the facility's structure makes hardest to perform. The surveillance definitions the IP uses are sound (Stone et al., 2012); the time to apply them is what varies.

What the Role Has That the Description Misses

Trust. Floor nurses call the IP first when something unusual happens, before the supervisor. Assistants ask the IP questions they would not ask the director of nursing. That trust comes from years in the building and from the staff development half of the role, which puts the IP in front of every new employee. A full-time IP without the education role might have more time and less trust, which is a trade a facility should make deliberately rather than by default.

What the Analysis Shows About the Role

The infection preventionist role is designed as a part-time specialist function but operates as a coordinator whose value depends on being reachable. Its expertise is real; its time is not protected. Nursing home infection preventionist staffing has remained low nationally (Stone et al., 2020), and this facility's split role is a common way of meeting the requirement on paper.

Sources

Each fact above came from one of the following, and the IP checked the description of the working week for accuracy on 1 October, correcting the hours spent on employee health upward and noting that outbreak weeks look completely different from ordinary ones. Observation over three weeks; the job description; the organizational chart; conversations with the IP, the director of nursing and the administrator; the facility's survey report from the previous year, shared by the administrator.

References

Centers for Medicare & Medicaid Services. (2016). Medicare and Medicaid programs; Reform of requirements for long-term care facilities (Final rule, 81 FR 68688). Federal Register.

Stone, N. D., Ashraf, M. S., Calder, J., Crnich, C. J., Crossley, K., Drinka, P. J., Gould, C. V., Juthani-Mehta, M., Lautenbach, E., Loeb, M., MacCannell, T., Malani, P. N., Mody, L., Mylotte, J. M., Nicolle, L. E., Roghmann, M.-C., Schweon, S. J., Simor, A. E., Smith, P. W., . . . Bradley, S. F. (2012). Surveillance definitions of infections in long-term care facilities: Revisiting the McGeer criteria. Infection Control & Hospital Epidemiology, 33(10), 965-977. https://doi.org/10.1086/667743

Stone, P. W., Agarwal, M., & Pogorzelska-Maziarz, M. (2020). Infection preventionist staffing in nursing homes. American Journal of Infection Control, 48(3), 330-332. https://doi.org/10.1016/j.ajic.2019.12.010