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Assisted living: A unique setting for quality care

By: Leslie Tripp, MSN/MHA, RN, RCFE

This growing field provides opportunities for nurses.


  • Nurses provide clinical leadership in assisted living.
  • The assisted living healthcare setting offers many nursing rewards and challenges.
  • Assisted living nurse skills include effective communication, creative problem-solving, strong clinical judgement, and critical thinking.

By Leslie Tripp, MSN/MHA, RN, RCFE

According to the U.S. Census Bureau, the number of residents age 65 and older increased from 35 million in 2000 to 49.2 million in 2016 and is projected to reach 98.2 million by 2060. Assisted living (AL) offers alternative living arrangements for older adults in various stages of their journey, and strong nurse leadership is fundamental to quality care and positive health outcomes.

What is assisted living?

assisted living setting quality care postIn the past, older adults requiring assistance with care had few options. Seniors who required assistance with activities of daily living (ADLs)—more than family could comfortably provide—were often moved to nursing homes, which were sterile and hospital-like. The desire for a more comfortable, homey environment led to the creation of AL communities. AL satisfies the desire for independence while also offering an environment where supervision by trained care-givers provides peace of mind to residents’ families.

The AL model is social rather than medical, focusing on activities, dining, and entertainment. Residents maintain their independence, and when they require assistance with ADLs or medication management, nurses provide that care in the homelike AL setting. In some organizations, clinical leadership at the community level is provided by licensed vocational nurses (LVNs) with regional RN oversight; other organizations provide RN clinical leadership in the community. Nursing oversight of chronic diseases requires strong leadership and a commitment to the beneficial social aspects of AL.

Nursing responsibilities

AL nursing is a misunderstood specialty; many mistakenly compare it to skilled nursing, which receives more on-site support. For example, in a skilled setting, a medical director is available on-site or over the phone for quick assessments and treatment ordering. AL, on the other hand, has no medical director; AL nurses are responsible for quickly communicating changes in residents’ conditions and coordinating care with each resident’s primary care provider. Skill requirements include strong clinical judgment, creative problem-solving, and critical thinking. Nurse objectives include reducing hospital visits, coordinating care with providers and specialists, and advocating for residents.

In addition to overseeing residents’ health and wellness, AL nurses must manage the wellness budget; supervise staff; recruit, hire, and train new employees; facilitate annual staff development; understand and comply with state regulations; and provide coaching and discipline. AL nurses also develop crucial partnerships with skilled nursing facilities (SNF), home health organizations, hospice agencies, and pharmacies. (See AL nursing skills and responsibilities.)

assisted living setting quality care nursing skills responsibilities


Working as an AL nurse comes with its challenges. For example, recruiting and retaining qualified staff continues to be a struggle in many AL settings. Studies report 36.4% caregiver turnover and 55.6% retention of qualified staff. Identifying the cause of the staffing crisis and developing solutions are necessary to maintain appropriate staff levels. AL staffing requirements include ensuring appropriate staff based on resident acuity. Currently, no national AL staff ratios exist. Visit to learn more about each state’s requirements.

Other challenges occur when residents are discharged from an SNF or hospital back to the AL setting. Some residents return with incomplete paperwork, including inadequate medication and treatment orders. This requires the AL nurse to spend time contacting hospital and primary care providers for orders and clarification. An AL nurse may have to work into the evening after receiving clarification orders from the provider to ensure medication technicians understand any new orders added to the electronic medication administration record. Another potential challenge is when discharge planners neglect to order equipment for delivery of oxygen or nebulizer treatments because ALs generally don’t have this on hand.


Nurses called to AL often have a desire to help create a memorable and pleasant experience for older adults. The rewards of AL nursing include getting to know the residents, involving them in activities, dancing alongside them at happy hour, celebrating milestones, and becoming part of their extended family.

Other rewards include holding residents’ hands as they grieve the loss of a loved one, supporting them after they hear a devastating diagnosis, and whispering to them in their final moments that it was an honor to know and love them.

One of the biggest rewards of AL nursing is taking care of older adults, advocating for them, and ensuring they receive the best services to guide them toward improved clinical outcomes and an enriched and fulfilled life.

Working in an AL environment provides nurses with leadership opportunities through the mainly autonomous structure. Successful AL nurses often receive additional duties—such as mentoring new nurses, facilitating group discussions, and presenting in meetings—that sharpen their management, leadership, and teaching skills. Many organizations promote from within when filling regional positions, providing nurses opportunities to support and advocate for even more residents and staff.

Compassion and leadership

AL communities require compassionate nurses with strong management skills who enjoy an autonomous clinical work environment, have mastered critical thinking, can make quick decisions, and can lead by example. In return, nurses have the opportunity to help promote residents’ health and wellness as well as their independence.

Leslie Tripp is the district director of clinical services at Brookdale Senior Living.

Selected references

Allen J. Overcoming staffing challenges in assisted living. Geriatr Nurs. 2017;38(1):83-4.

U.S. Census Bureau. Facts for features: Older Americans Month: May 2017. April 2017.

U.S. Census Bureau. The nation’s older population is still growing, Census Bureau reports. June 22, 2017.


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