HLTH 1005 Week 9 Nursing Home Workforce Analysis Example

Who Works the Night Shift in a 90-Bed Nursing Home: Roles, Credentials, Federal Minimums and What One Unfilled Nursing Assistant Position Moves Onto Everyone Else

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Walden University

HLTH 1005: Context of Healthcare Delivery

Instructor Name

Month Day, Year

Who Works the Night Shift in a 90-Bed Nursing Home: Roles, Credentials, Federal Minimums and What One Unfilled Nursing Assistant Position Moves Onto Everyone Else

The Setting

Discussions of the health care workforce usually begin with national shortage figures. This paper begins with a roster. The setting is a 90-bed nursing home certified for both Medicare and Medicaid, in a state whose nurse practice act follows the common pattern of registered nurses, licensed practical nurses and certified nursing assistants. The facility, its census and its schedule are a composite built for this assignment; the federal rules cited are real. The analysis lists the roles on one shift, states what each is credentialed and permitted to do, and then follows one unfilled nursing assistant position through a week of night shifts to show who absorbs the gap.

The Roster and What Each Credential Means

Four words describe the people on the floor, and outside the building they are treated as interchangeable. They do not.

Licensed. Registered nurses and licensed practical nurses hold a state license issued under the state's nurse practice act after completing an approved program and passing a national licensing examination. The license defines a scope of practice that the state can enforce. In most states, a registered nurse can perform comprehensive assessments and develop care plans, while a licensed practical nurse carries out focused tasks, such as most medications and treatments, with a registered nurse or physician directing the work.

Certified. Nursing assistants in a Medicare or Medicaid certified nursing home must complete a state-approved training and competency evaluation program. Federal rules require that such programs include at least 75 clock hours of training, with at least 16 hours of supervised practical training (42 C.F.R. § 483.152). Passing the program places the assistant on the state's nurse aide registry. Certification allows bathing, dressing, feeding, toileting, repositioning and taking vital signs, but not giving medications or assessing patients.

Registered. In this context, the word refers to the nurse aide registry, not to registered nursing. A nursing assistant listed on the registry is not a registered nurse, a confusion that families make often.

Unlicensed. Dietary aides, housekeepers and activity staff hold no health care license or certification. They are essential to residents' days but may not perform hands-on care tasks.

Federal rules also set minimums for licensed staff: the facility needs a registered nurse on site for an unbroken eight hours every day of the week, a full-time director of nursing who is a registered nurse and a licensed nurse designated as charge nurse on each shift (42 C.F.R. § 483.35). Beyond these minimums, the rules require staffing that is sufficient to meet residents' needs, without setting a ratio for nursing assistants.

The Night Shift as Scheduled

For the overnight shift, which runs 2300 to 0700, the facility schedules one licensed practical nurse as charge nurse for each of its two 45-bed halls, and six certified nursing assistants, three per hall. The registered nurse coverage required by federal rules falls on the day and evening shifts, so at night the registered nurse is the director of nursing, on call by phone. With 88 residents in the building, each nursing assistant is responsible for about 15 residents. Overnight work includes turning residents who cannot move themselves every two hours, answering call lights, changing incontinence briefs, helping residents to the bathroom and starting morning care for early risers before 7 a.m.

Following One Unfilled Position

Now suppose one night nursing assistant resigns, and the position stays open for six weeks. On nights when no one picks up the shift, the five remaining assistants divide 88 residents, about 18 each. The facility has three options, and each moves the gap onto someone different.

Option 1: Work short. The five assistants absorb three extra residents each. Two-hour turning schedules slip, call lights wait longer and early morning care is pushed onto the day shift, which then starts behind. The burden lands first on residents, especially those who depend on staff to move, and second on the day shift.

Option 2: Mandatory overtime or a double shift. An evening assistant is asked to stay until 7 a.m., working 16 hours. The gap moves onto that worker's fatigue and family life, and research on nursing home staffing links heavy workloads and turnover to worse quality (Castle & Engberg, 2005). Repeated mandatory overtime can push a second assistant to resign, which turns one vacancy into two.

Option 3: Agency staff. A staffing agency fills the shift at a higher hourly cost. The gap moves onto the budget and, less visibly, onto the regular staff and the charge nurse, who must orient a worker who does not know the residents, their routines or the building.

In practice the facility uses all three in different weeks, and the charge nurses fill some of the gap themselves by answering call lights, which takes time from medication passes and assessments that only licensed staff can do. One unfilled position therefore spreads across every role on the shift.

What the Analysis Shows

Nursing assistants provide most of the hands-on care in nursing homes, and federal rules set training minimums for them but no staffing ratio. That makes the nursing assistant position the most flexible line on the schedule and therefore the first to stretch. The Bureau of Labor Statistics projects continued demand for nursing assistants as the population ages (U.S. Bureau of Labor Statistics, n.d.), which suggests the vacancy in this example is not unusual. For an administrator, the lesson is that the cost of a vacancy is not the unpaid wage saved but the overtime, agency fees, missed care and further turnover it sets off. Retention measures, such as predictable schedules, consistent assignments to the same residents and career steps from nursing assistant to licensed practical nurse, may cost less than the gap they prevent.

An administrator can also measure the cost of a vacancy directly: overtime hours, agency invoices, call-light response times and resident falls on short nights can all be tracked week by week, which turns a staffing argument into numbers a budget meeting can weigh.

References

Castle, N. G., & Engberg, J. (2005). Staff turnover and quality of care in nursing homes. Medical Care, 43(6), 616-626. https://doi.org/10.1097/01.mlr.0000163661.67170.b9

Nursing services, 42 C.F.R. § 483.35 (2024).

Requirements for approval of a nurse aide training and competency evaluation program, 42 C.F.R. § 483.152 (2024).

U.S. Bureau of Labor Statistics. (n.d.). Nursing assistants and orderlies. Occupational Outlook Handbook. https://www.bls.gov/ooh/healthcare/nursing-assistants.htm