Are Staffing, Work Environment, Work Stressors, and Rationing of Care Related to Care Workers' Perception of Quality of Care? A Cross-Sectional Study

Development and psychometric properties of an instrument to evaluate missed nursing care in home care: A validation study

OBJECTIVE

To develop and validate a questionnaire to evaluate missed nursing care (MNC) in a home care setting.

DESIGN

A new instrument was developed and tested performing a preliminary analysis of a multicenter cross-sectional study in Italy. Reporting was performed according to COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) guidelines.

SAMPLE

Eight hundred out of a total of 2549 home care nurses enrolled in AIDOMUS-IT were considered for the validation of the Missed Nursing Care in Home Care (MNC_HC).

MEASUREMENTS

The MNC_HC instrument was developed by a panel of experts and underwent content and face validation. Exploratory (EFA) and confirmatory factor analyses (CFA) were conducted.

RESULTS

EFA revealed a one-factor solution, explaining 56% of the total variance for MNC_HC. CFA confirmed excellent structural validity, with a one-factor model showing an exceptional fit (χ2 (27) = 141.39, p < .001, RMSEA = 0.04, SRMR = 0.04, CFI = 0.99, TLI = 0.99, factor loadings > 0.5). MNC_HC also demonstrated high reliability (Cronbach's α = 0.92). The activity with the highest rate of missed care was the documentation of nursing care (77%), while activities related to nursing techniques (e.g., injections, dressings, etc.) were reported to be missed less (33.63%).

CONCLUSIONS

MNC_HC is a quick-filling, valid, reliable, and psychometrically sound instrument for measuring MNC in home care useful for future research.

The role of workday characteristics on perceived stress and time pressure among nurses in Finnish long-term care - a cross-sectional study

BACKGROUND

Aging populations and nursing workforce issues are causing challenges for long-term care globally, and therefore, improving the work-related wellbeing and retention of nurses is crucial. As such, gaining a further understanding of the factors that affect work strain in long-term care is important. Previously, the effect of job demands on the wellbeing of nurses has been researched principally by subjective instruments. In this study, we examined the relationship between indirectly measured workday characteristics and perceived stress and time pressure among nurses working in Finnish long-term care (assisted living facilities with 24-hour assistance).

METHODS

A total of 503 nurses from 44 assisted living facilities across Finland completed time measurement surveys and wellbeing questionnaires. The data were linked with client characteristics from the Resident Assessment Instrument register. The relationships between the measured number of care events during the workday, clients' care needs, and the amount of breaktime and perceived stress and time pressure were analyzed using multivariate logistic regression.

RESULTS

Nurses who had more care events and clients with greater care needs were at higher odds of having high stress. More care events and reduced breaktime were associated with high time pressure. Disruptions during the workday were strongly associated with both high stress and time pressure. Last, nurses who were under high stress and time pressure worked more often in teams with lower team autonomy.

CONCLUSIONS

Our findings on indirectly measured job demands indicate that dividing the workload equally among nurses through better work division can help reduce the stress and time pressure of nurses in long-term care. In addition, ensuring sufficient breaktime and preventing unnecessary disruptions is important. To help recruit and retain the care workforce, fair management of work that accounts for varying client care needs and workload is needed. In addition, legislative and governance tools, such as staffing level regulation, and further consideration of job demands might aid in reducing the job strain of nurses.

PATIENT OR PUBLIC CONTRIBUTION

Patients or nurses were not involved in the design of the study, analysis, or interpretation of the results, or in the preparation of the manuscript.

Care quality and safety in long-term aged care settings: A systematic review and narrative analysis of missed care measurements

AIM

To critically evaluate missed care measurement approaches and their application in long-term aged care (LTAC) settings.

DESIGN

Systematic review using Tawfik's guideline.

DATA SOURCES

PubMed, Scopus, Web of Science, CINAHL and ProQuest were searched. Supplemental searching was from reference lists of retrieved records, first authors' ORCID homepages and Google advanced search for grey literature. Search limitations were English language, published between 1 January 2001 and 31 December 2022.

REVIEW METHOD

COVIDENCE was utilized for screening, data extraction and quality appraisal. JBI Critical Appraisal Tools and COSMIN Risk of Bias Tool were used for quality appraisal. Data were summarized and synthesized using narrative analysis.

RESULTS

Twenty-four publications across 11 regions were included, with two principal methods of missed care measurement: modified standard scales and tailored specific approaches. They were applied inconsistently and generated diverse measurement outcomes. There were challenges even with the most commonly used tool, the BERNCA-NH, including absence of high-quality verification through comparative analysis against an established 'gold standard', reliance on self-administration, incomplete assessment of constructs and inadequate exploration of psychometric properties.

CONCLUSION

Globally, there are deficiencies in the effectiveness and comprehensiveness of the instruments measuring missed care in LTAC settings. Further research on theoretical and practical perspectives is required.

IMPLICATIONS

Findings highlighted a critical need to establish a standardized, validated approach to measure missed care in LTAC settings. This review calls for collaborative efforts by researchers, clinical staff and policymakers to develop and implement evidence-based practices as a way of safeguarding the well-being of older clients living in LTAC settings.

IMPACT

Measurements of missed care in LTAC settings rely on adapting acute care tools. There is a critical gap in measuring missed care in LTAC settings. Developing a new tool could improve care quality and safety in LTAC settings globally.

REPORTING METHOD

Adhered to PRISMA guideline.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Utilizing the physical green care environment to support activities of daily living for nursing home residents: a focused ethnographic case study

BACKGROUND

The nursing home residents' ability to carry out Activities of Daily Living (ADLs) is influenced by the physical care environment. One emerging area of interest in scientific research is the green care environment within nursing home care, where agricultural activities such as gardening and animal care are integrated alongside daily care. Previous research has neglected to explore how these environments can be employed to enhance ADL performance. This study, therefore, explores how a green care environment, specifically one with an animal shelter, can be used to support nursing home residents in their ADLs.

METHODS

A focused ethnographic case study was conducted in one nursing home. Data was collected employing participatory observations, informal conversations, and semi-structured interviews, which we analyzed by employing a thematic analysis.

RESULTS

Overall, 25 residents were observed for a total time of 89h, and interviews were conducted with 10 staff members. The nursing home integrates activities in the green care environment into daily care for a broad scope of residents. The analysis revealed four themes: (1) The (in)visibility of ADL, (2) Reciprocal care dynamics: Fostering ADL performance through connection and teamwork, (3) Seized and missed opportunities for meaningful integration of ADL in the physical green care environment, and Theme (4) Professional fulfillment and ADL task obligation: Views from staff and management.

CONCLUSIONS

This physical green care environment carries the potential to enhance the residents' daily activities and foster better staff-resident relationships. Yet, there are varying views among staff and management regarding its integration into the residents' lives and care.

Associations between nursing home care environment and unfinished nursing care explored. Secondary analysis of cross-sectional data

Understanding unfinished nursing care and its relationship with modifiable care environment factors is crucial for the service delivery to long-term frail patients. This secondary analysis aimed to explore the associations between characteristics of the care environment and unfinished nursing care, as reported by nursing care workers in Norwegian nursing homes. Of 931 respondents (37% response rate) from 66 nursing homes, six care environment characteristics correlated with at least two types of unfinished nursing care. Resources and Multidisciplinary collaboration showed a positive association with all four unfinished care categories. Input and acknowledgement, Professional, or Interpersonal leadership were not associated to unfinished care. In summary, our findings suggest that nursing care workers reporting positive care environment descriptions also reported lower frequencies of unfinished nursing care. This study offers insights crucial for human resource management which ultimately can be used to improve patient outcomes in nursing homes.

Flanders Nursing Home (FLANH) project: Protocol of a multicenter longitudinal observational study on staffing, work environment, rationing of care, and resident and care worker outcomes

BACKGROUND

While the demand for high quality of care in nursing homes is rising, it is becoming increasingly difficult to recruit and retain qualified care workers. To date, evidence regarding key organizational factors such as staffing, work environment, and rationing of care, and their relationship with resident and care worker outcomes in nursing homes is still scarce. Therefore, the Flanders Nursing Home (FLANH) project aims to comprehensively examine these relationships in order to contribute to the scientific knowledge base needed for optimal quality of care and workforce planning in nursing homes.

METHODS

FLANH is a multicenter longitudinal observational study in Flemish nursing homes based on survey and registry data that will be collected in 2023 and 2025. Nursing home characteristics and staffing variables will be collected through a management survey, while work environment variables, rationing of care, and care worker characteristics and outcomes will be collected through a care worker survey. Resident characteristics and outcomes will be retrieved from the Belgian Resident Assessment Instrument for long-Term Care Facilities (BelRAI LTCF) database. Multilevel regression analyses will be applied to examine the relationships between staffing variables, work environment variables, and rationing of care and resident and care worker outcomes.

CONCLUSION

This study will contribute to a comprehensive understanding of the nursing home context and the interrelated factors influencing residents and care workers. The findings will inform the decision-making of nursing home managers and policymakers, and evidence-based strategies to optimize quality of care and workforce planning in nursing homes.

Administrative burden in Swiss nursing homes and its association with care workers' outcomes-a multicenter cross-sectional study

BACKGROUND

Care workers in nursing homes often perform tasks that are rather related to organizational or management activities than 'direct patient care'. 'Indirect care activities', such as documentation or other administrative tasks are often considered by care workers as a burden, as they increase overall workload and keep them away from caring for residents. So far, there is little investigation into what kind of administrative tasks are being performed in nursing homes, by which type of care workers, and to which extent, nor how administrative burden is associated with care workers' outcomes.

PURPOSE

The objective of this study was to describe care workers' administrative burden in Swiss nursing homes and to explore the association with four care worker outcomes (i.e., job dissatisfaction, emotional exhaustion, intention to leave the current job and the profession).

METHODS

This multicenter cross-sectional study used survey data from the Swiss Nursing Homes Human Resources Project 2018. It included a convenience sample of 118 nursing homes and 2'207 care workers (i.e., registered nurses, licensed practical nurses) from Switzerland's German- and French-speaking regions. Care workers completed questionnaires assessing the administrative tasks and burden, staffing and resource adequacy, leadership ability, implicit rationing of nursing care and care worker characteristics and outcomes. For the analysis, we applied generalized linear mixed models, including individual-level nurse survey data and data on unit and facility characteristics.

RESULTS

Overall, 73.9% (n = 1'561) of care workers felt strongly or rather strongly burdened, with one third (36.6%, n = 787) reporting to spend 2 h or more during a "normal" day performing administrative tasks. Ratings for administrative burden ranged from 42.6% (n = 884; ordering supplies and managing stocks) to 75.3% (n = 1'621; filling out the resident's health record). One out of four care workers (25.5%, n = 561) intended to leave the profession, whereby care workers reporting higher administrative task burden (OR = 1.24; 95%CI: 1.02-1.50) were more likely to intend to leave the profession.

CONCLUSION

This study provides first insights on care workers' administrative burden in nursing homes. By limiting care workers' burdensome administrative tasks and/or shifting such tasks from higher to lower educated care workers or administrative personnel when appropriate, nursing home managers could reduce care workers' workload and improve their job satisfaction and retention in the profession.

Validation of the Basel Extent of Rationing of Nursing Care for Nursing Homes and Home Care, a Swedish version

AIM

The aim of the study was to translate, adapt and validate the instrument Basel Extent of Rationing of Nursing Care for Nursing Homes and Home Care for use in the Swedish community health care context.

DESIGN

A cross-sectional study. Data were collected from October 2019 to January 2020, and the questionnaire was sent to Registered Nurses, Enrolled Nurses and assistant nurses.

METHODS

The study was performed in four phases: (1) translation, (2) adaptation of the Basel Extent of Rationing of Nursing Care for Nursing Homes and Home Care to the Swedish context, (3) content validity testing, and (4) evaluation of psychometric properties. The collected data resulted in 611 responses. Explorative factor analysis was performed to explore the interrelationship, and Cronbach's alpha was used to evaluate the internal consistency.

RESULTS

Explorative factor analysis presented six factors/subscales: (1) fundamental care, (2) timely needed-based care, (3) dignity and support, (4) ensuring respectful treatment, (5) social activities, and (6) documentation, planning and reporting. The Cronbach's alpha for the components showed values between 0.7 and 0.9.

CONCLUSION

The analyses indicate an instrument to be usable for Enrolled Nurses and nurse assistants in community health care. Additional tests, can contribute to refining the content of the items and further test reliability and validity of the instrument.

NO PATIENT OR PUBLIC CONTRIBUTION

As this is a study of translation and validation of the instrument Basel Extent of Rationing of Nursing Care for Nursing Homes and Home Care.

Well-being of professional older adults' caregivers in Alberta's assisted living and long-term care facilities: a cross-sectional study

BACKGROUND

For the care need of older adults, long-term care (LTC) and assisted living (AL) facilities are expanding in Alberta, but little is known about the caregivers' well-being. The purpose of the study was to investigate the physical health conditions, mental and emotional health (MEH), health behaviour, stress levels, quality of life (QOL), and turnover and absenteeism (TAA) among professional caregivers in Alberta's LTC and AL facilities.

METHODS

This cross-sectional survey involved 933 conveniently selected caregivers working in Alberta's LTC and AL facilities. Standardised questions were selected from the Canadian Community Health Survey, Patient Health Questionnaire-9, and Short Form-36 QOL survey revalidated and administered to the participants. The new questionnaire was used to assess the caregivers' general health condition (GHC), physical health, health behaviour, stress level, QOL, and TAA. Data were analysed using descriptive statistics, Cronbach alpha, Pearson's correlation, one-way analysis of variance, and multiple linear regression.

RESULTS

Of 1385 surveys sent to 39 facilities, 933 valid responses were received (response rate = 67.4%). The majority of the caregivers were females (90.8%) who were ≥ 35 years (73.6%), worked between 20 to 40 h weekly (67.3%), and were satisfied with their GHC (68.1%). The Registered Nurses had better GHC (mean difference [MD] = 0.18, p = 0.004) and higher TAA than the Health Care Aides (MD = 0.24, p = 0.005). There were correlations between caregivers' TAA and each of MEH (r = 0.398), QOL (r = 0.308), and stress (r = 0.251); p < 0.001. The most significant predictors of TAA were the propensity to quit a workplace or the profession, illness, job stress, and work-related injury, F (5, 551) = 76.62, p < 0.001, adjusted R² = 0.998.

CONCLUSION

Reducing the caregivers' job stressors such as work overload, inflexible schedule, and poor remuneration, and improving their quality of life, health behaviour, and mental, emotional, and physical health conditions may increase their job satisfaction and reduce turnover and absenteeism.

Longitudinal changes in nursing home leadership, direct care staff job strain and social support in Swedish nursing homes-findings from the U-AGE SWENIS study

BACKGROUND

Promoting healthy work environment as a manager in nursing homes is important to safeguard staff health and well-being as well as care quality when facing increasing demands. The impact of leadership on staff work environment needs further exploration.

OBJECTIVES

To describe longitudinal changes in nursing home leadership, direct care staff characteristics, job strain and social support.

METHODS

This study has a repeated cross-sectional design, a five-year follow-up study. Nursing home staff in 181 corresponding units (n = 1253 in 2014 and n = 1176 in 2019) completed surveys about leadership, staff job strain and social support in a five-year follow-up study. Descriptive and regression analyses were conducted.

RESULTS

A higher degree of leadership defined by coaching and providing direct feedback to care staff, handling conflicts in a constructive way and having control of the clinical work, was significantly associated with a lower degree of job strain and a higher degree of social support among staff, with stronger associations at follow-up. The proportion of enrolled nurses increased significantly at follow-up.

CONCLUSIONS

Leadership is increasingly important for staff work environment, especially in times of increased workload and decreasing collegiality and deteriorating work atmosphere at work.

IMPLICATIONS FOR PRACTICE

Stakeholder and policy makers in nursing home care may reflect on how managers' leadership is prioritised in these environments because such leadership is associated with staff job strain and social support. Managers striving to improve the work situation of staff may consider their own role and allow flexibility in how and when the work can be performed.

Workload and quality of nursing care: the mediating role of implicit rationing of nursing care, job satisfaction and emotional exhaustion by using structural equations modeling approach

Background

Nursing workload and its effects on the quality of nursing care is a major concern for nurse managers. Factors which mediate the relationship between workload and the quality of nursing care have not been extensively studied. This study aimed to investigate the mediating role of implicit rationing of nursing care, job satisfaction and emotional exhaustion in the relationship between workload and quality of nursing care.

Methods

In this cross-sectional study, 311 nurses from four different hospitals in center of Iran were selected by convenience sampling method. Six self-reported questionnaires were completed by the nurses. The data were analyzed by SPSS version 16. Structural equation modeling was used to determine the relationships between the components using Stata 14 software.

Results

Except direct and mutual relationship between workload and quality of nursing care (P ≥ 0.05), the relationship between other variables was statistically significant (P < 0.05). The hypothesized model fitted the empirical data and confirmed the mediating role of implicit rationing of nursing care, job satisfaction and emotional exhaustion in the relationship between workload and the quality of nursing care (TLI, CFI > 0.9 and RMSEA < 0.08 and χ²/df < 3).

Conclusion

Workload affects the quality of the provided nursing care by affecting implicit rationing of nursing care, job satisfaction and emotional exhaustion. Nurse managers need to acknowledge the importance of quality of nursing care and its related factors. Regular supervision of these factors and provision of best related strategies, will ultimately lead to improve the quality of nursing care.

Identifying the Service Capability of Long-Term Care Facilities in China: An e-Delphi Study

Objective

This study develops a group of service capability indicators for long-term care facilities to assess their current conditions and makes it the first step toward the improvement of service capability in China.

Methods

We constructed an initial indicator framework based on the characteristics of long-term care services and a literature review. Potential indicators were collected, and a 2-round modified web-based Delphi process was conducted by a national multidisciplinary expert panel to construct a service capability evaluation index system. The accepted competencies of indicators were established with mean scores in all three scoring criteria (importance, feasibility, and sensitivity) ≥ 4.0, consensus rate reached 70.0%, and a coefficient of variation ≤ 0.25.

Results

A new indicator framework covering 2 dimensions of inputs and activities was developed in this study. The initial 35 indicators formed an indicator pool for the Delphi questionnaire. According to the final consensus of the expert panel, the Delphi consultation resulted in an index system comprised 31 tertiary indicators across six subdimensions (i) staffing; (ii) facilities and equipment; (iii) funding; (iv) medical inspection services; (v) health management services; (vi) institutional standard management.

Conclusion

This study developed a set of indicators suitable for the long-term care system in China and is expected to be applied to measure and improve the service capability of long-term care facilities. In addition, these indicators can be used for comparisons between different LTCFs and provide an evidence basis for the further development of capability assessment tools.

Increasing implicit rationing of care in nursing homes: A time-series cross-sectional analysis

BACKGROUND

Implicit rationing of nursing care is a socio-ecological problem where care workers, due to lack of resources, have to leave necessary nursing care activities undone. Cross-sectional studies on implicit rationing of nursing home care revealed associations with organizational and work environment characteristics. However, little is known on how implicit rationing of nursing care varies over time in nursing homes.

OBJECTIVE

This study's purpose was to describe changes in levels and patterns of implicit rationing of nursing care in Swiss nursing homes over time, while accounting for key explanatory factors related to organizational, work environment, and individual characteristics.

DESIGN

Time-series cross-sectional analysis.

SETTING

Nursing homes in Switzerland.

PARTICIPANTS

A convenience sample of 47 nursing homes and 3269 care workers from all educational levels participating in two multicenter cross-sectional studies (the Swiss Nursing Home Human Resources Project) conducted in 2013 and 2018.

METHODS

To quantify implicit rationing of nursing care, care workers' data were collected via the nursing home version of the Basel Extent of Rationing of Nursing Care instrument. To control for leadership ability, staffing and resource adequacy, we used the Nursing Work Index-Practice Environment Scale. Objective measures including turnover, staffing and skill mix levels were aggregated at the nursing home level. Our analyses included multiple linear mixed models, using time as a fixed effect and nursing home as a random effect.

RESULTS

We found overall increases of rationing of care activities over the five-year period studied, with documentation and social activities most rationed at both measurement points (overall coefficients varied between 0.11 and 0.23, as well as the 95%-confidence intervals between 0.05 and 0.30). Moreover, a considerable increase in rationing of activities of daily living (coefficient of 0.47 in 2013 and 0.63 in 2018) was observed.

CONCLUSIONS

Alongside long-term deterioration of staff resources, increases in rationing of nursing care are a worrying development, particularly given their potential negative impacts both on residents and on care workers. To assess nursing home care quality and to determine adequate staffing levels and skill mixes, policy makers and nursing home managers should consider regular monitoring of rationing of nursing care.

TWEETABLE ABSTRACT

Time-series cross-sectional analysis reveals increasing rationing of nursing care activities in Swiss nursing homes from 2013 to 2018.

More than just staffing? Assessing evidence on the complex interplay among nurse staffing, other features of organisational context and resident outcomes in long-term care: a systematic review protocol

INTRODUCTION

Especially in acute care, evidence points to an association between care staffing and resident outcomes. However, this evidence is more limited in residential long-term care (LTC). Due to fundamental differences in the population of care recipients, organisational processes and staffing models, studies in acute care may not be applicable to LTC settings. We especially lack evidence on the complex interplay among nurse staffing and organisational context factors such as leadership, work culture or communication, and how these complex interactions influence resident outcomes. Our systematic review will identify and synthesise the available evidence on how nurse staffing and organisational context in residential LTC interact and how this impacts resident outcomes.

METHODS AND ANALYSIS

We will systematically search the databases MEDLINE, EMBASE, CINAHL, Scopus and PsycINFO from inception for quantitative research studies and systematically conducted reviews that statistically modelled interactions among nurse staffing and organisational context variables. We will include original studies that included nurse staffing and organisational context in LTC as independent variables, modelled interactions between these variables and described associations of these interactions with resident outcomes. Two reviewers will independently screen titles/abstracts and full texts for inclusion. They will also screen contents of key journals, publications of key authors and reference lists of all included studies. Discrepancies at any stage of the process will be resolved by consensus. Data extraction will be performed by one research team member and checked by a second team member. Two reviewers will independently assess the methodological quality of included studies using four validated checklists appropriate for different research designs. We will conduct a meta-analysis if pooling is possible. Otherwise, we will synthesise results using thematic analysis and vote counting.

ETHICS AND DISSEMINATION

Ethical approval is not required as this project does not involve primary data collection. The results of this study will be disseminated via peer-reviewed publications and conference presentation.

PROSPERO REGISTRATION NUMBER

CRD42021272671.

Quality of nursing care in Saudi's healthcare transformation era: A nursing perspective

BACKGROUND

The Kingdom of Saudi Arabia corporates performance improvement strategies in health sector to transform hospital operations and instituting a culture of quality through performance improvement initiatives. Quality of nursing care (QNC) is a concern for nursing professionals and administration. Donabedian's 'Quality-of-Care' framework plays a vital role in transforming nursing care and determining appropriate intervention development and implementation plans.

AIM

To explore the nurses' perception for the QNC and find their perspectives in achievements and gaps by adopting the Donabedian model.

METHODS

A cross-sectional study was conducted on a convenience sample of 639 nurses from a tertiary hospital in Saudi Arabia using Karen-personnel instrument for measuring QNC. The achievements and gaps in nursing care quality determined by redistributing Karen statements to the three dimensions of the Donabedian structure, process and outcome model.

FINDINGS

The nurses' overall perception of the QNC was positive. According to the Donabedian model, the nurses focussed on care procedures (i.e., process-oriented) and required resources (i.e., structure-oriented), although the transformation era requires nurses' performance to focus on the outcome dimension.

CONCLUSION

To activate the vital roles of nurses in accomplishing health transformation initiatives, there should be collaborative efforts among nursing managers, educators and policy-makers to sustain quality of structure, process and outcome-oriented nursing care and be more outcome-oriented.

Prevalence, type, and reasons for missed nursing care in municipality health care in Sweden – A cross sectional study

Background

With an ageing population, there is an increasing need for care, both as home care and in nursing homes. However, some needed care is not carried out for different reasons, which can affect patient safety. The aim of the study was to describe prevalence, type, and reasons for missed nursing care in home care and nursing homes, from nurses’ perspective.

Methods

A cross sectional design with quantitative and qualitative approach. A Swedish version of Basel Extent of Rationing of Nursing Care for nursing homes and 15 study specific questions were answered by 624 registered nurses, enrolled nurses, or nurse assistants. Both descriptive and analytical, independent-samples t-test, analyses were used. Qualitative content analysis was used for the open-ended question.

Results

The care activity most often missed in home care was: ‘set up or update care plans’ (41.8%), and in nursing homes: ‘scheduled group activity’ (22.8%). Reasons for missed nursing care were lack of preparedness for unexpected situations, obstacles in a deficient work environment, unsatisfactory planning in the organisation, and/or shortcomings related to the individual.

Conclusion

Not all care activities needed are performed, due to reasons such as lack of time or organisational issues. Missed nursing care can lead to adverse events and affect patient safety. It is important to be aware of missed nursing care and the reasons for it, which gives a possibility to initiate quality improvement work to ensure patient safety.

Does context count? The association between quality of care and job characteristics in residential aged care and hospital settings: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Within residential aged care settings, reduced quality of care (QOC), abuse, and neglect have been global phenomena which require urgent intervention. As the reported rate of these problems is much higher in aged care compared to hospital settings, we investigated whether differing job design characteristics between the two settings might explain the difference.

RESEARCH DESIGN AND METHODS

We used a meta-analysis to compare differences in the relationships between high job demands, low job resources, and job strain with QOC and counter-productive work behaviors (CWBs) across aged care and hospital settings.

RESULTS

Data was extracted from 42 studies (n=55 effects). QOC was negatively correlated with high job demands (ρ̅ =-.22, 95% CI: -.29:-.15, k=7), low job resources (ρ̅ = -.40, 95% CI:-.47:-.32, k=15), and job strain (ρ̅ =-.32, 95% CI: -.38:.-.25, k=22), CWBs had a positive relationship with job demands (ρ̅ =.35, 95%CI: .10:.59, k=3) and job strain (ρ̅ =.34, 95% CI: .13:.56, k=6). The association between poor QOC and low job resources was stronger in aged care (r=-.46, 95% CI:-.55:-36, k=8) than in hospital settings (r= -.30, 95% CI:-.41:-.18, k=7).

DISCUSSION AND IMPLICATIONS

Our findings suggest that relationships between low job resources and poor quality of care are exacerbated in residential aged care contexts. To improve care outcomes, stakeholders should improve job resources such as skill discretion, supervisory supports, and increased training and staffing levels in residential aged care.

Developing a Scale of Care Work-Related Quality of Life (CWRQoL) for Long-Term Care Workers in England

BACKGROUND

Long-term care (LTC) workers are subjected to structural and inherent difficult conditions that are likely to impact their quality of life at work; however, no agreed scale measures it. This study aims to develop a scale to measure the work-related quality of life among LTC workers in England (CWRQoL). The study establishes the domains/sub-domains of CWRQoL, investigates the tool's utility and collates information on existing supporting strategies for CWRQoL.

METHODS

We adopt a mixed-methods approach employing inductive/deductive processes at three stages: (1) a scoping review of the literature; (2) interviews and focus groups with frontline LTC workers, managers and LTC stakeholders; and (3) a content validity consensus survey.

RESULTS

CWRQoL is composed of seven domains (and 23 sub-domains). Additional domains to those in the literature include financial wellbeing, sufficient time for building relations, managing grief and emotions associated with client death and end of life care. Stakeholders identified several benefits and challenges related to the CWRQoL tool's utility. COVID-19 significantly impacted LTC workers' mental wellbeing and spillover between work and home.

CONCLUSIONS

The study highlighted the complex nature of CWRQoL and provided a solid ground for developing and validating a CWRQoL scale.

The Impact of Nursing Staffs’ Working Conditions on the Quality of Care Received by Older Adults in Long-Term Residential Care Facilities: A Systematic Review of Interventional and Observational Studies

Background: Little documentation exists on relationships between long-term residential care facilities (LTRCFs), staff working conditions and residents’ quality of care (QoC). Supporting evidence is weak because most studies examining this employ cross-sectional designs. Methods: Systematic searches of twelve bibliographic databases sought experimental and longitudinal studies, published up to May 2021, focusing on LTRCF nursing staff’s working conditions and the QoC they provided to older adults. Results: Of the 3577 articles identified, 159 were read entirely, and 11 were retained for inclusion. Higher nursing staff hours worked per resident per day (HPRD) were associated with significant reductions in pressure sores and urinary tract infections. Overall staff qualification levels and numbers of RNs had significant positive influences on QoC. Conclusions: To the best of our knowledge, this systematic review is the first to combine cohort studies with a quasi-experimental study to explore associations between LTRCF nursing staff’s working conditions and older adult residents’ QoC. Human factors (including HPRD, staff turnover, skill mix, staff ratios) and the specific working contribution of RNs had overwhelmingly significant influences on QoC. It seems essential that LTRCF supervisory and decision-making bodies should promote optimal working conditions for nursing staff because these have such a direct impact on residents’ QoC.

Missed Nursing Care in a Sample of High-Dependency Italian Nursing Home Residents: Description of Nursing Care in Action

OBJECTIVE

The aim of the study was to describe omitted or delayed nursing care (i.e., missed nursing care [MNC]) in a sample of Italian nursing homes (NHs).

METHODS

Nurses from 50 NHs located in Northern Italy selected the 20 most dependent residents in their care and reported instances of MNC for three to five consecutive shifts. They described the type of MNC, its cause(s), management, recurrence, and severity of possible consequences for the resident. Information on the residents and the NH was also collected. The instances of MNC were classified as potentially avoidable/preventable or not.

RESULTS

Overall, 266 (85.3%) of 312 nurses participated and 1000 residents were observed during 381 shifts (164 mornings, 164 afternoons, and 53 nights); 101 (38%) nurses reported 223 instances of MNC among 175 residents (17.5%). Ninety-seven omissions and 109 delays occurred during the day shift (56 omissions were delegated to the next shift). The most frequent MNC was drug administration (n = 71, 34.5%). In 24 (44.4%) of 54 instances of delayed drug administration, the delay was less than 30 minutes. Nurses rated approximately 20% of MNC (n = 41) as highly severe because of the discomfort caused to the resident, the clinical impact, or the repetitiveness of the situation. Nurses ascribed almost half of MNC (n = 100, 48.5%) to inadequate staffing, and they categorized 26 (11.6%) instances of MNC as unavoidable.

CONCLUSIONS

The number of nurse-reported instances of MNC we reported was much lower than that previously collected with available instruments. Most MNC did not impact the comfort and safety of residents. A certain proportion of MNC was unavoidable.

Nursing Home Senior Managers and Direct Care Staff: Are There Differences in Their Perceptions of Safety Climate?

OBJECTIVES

Improving nursing home safety is important to the quality of resident care. Increasing evidence points to the relationship between actual safety and a strong safety climate, i.e., staff agreement about safety norms. This national study focused on Veterans Health Administration nursing homes (Community Living Centers [CLCs]), assessing direct care staff and senior managers' agreement about safety norms.

METHODS

We recruited all 134 CLCs to participate in the previously validated CLC Employee Survey of Attitudes about Resident Safety. To assess whether safety climate domains (7) differed by management level and by direct care staff occupation, we estimated multilevel linear regression models with random effects clustered by CLCs, medical center, Department of Veterans Affairs 2017 integrated service network (n = 20), and region.

RESULTS

Of the 5288 individuals we e-mailed, 1397 (25.7%) completed surveys, with participation from 56 CLCs or 41.8% of 134 CLCs. In our analysis of 1316 nurses, nursing assistants, clinicians/specialists, and senior managers, senior managers rated co-worker interactions around safety (P < 0.0013) and overall safety in their CLC (P < 0.0001) more positively than did direct care staff. In contrast, on these same two domains, direct care groups had similar perceptions, though differing significantly in safety priorities, safety attitudes, and senior management commitment to safety.

CONCLUSIONS

In this national sample of nursing homes in one of the largest integrated U.S. healthcare systems, direct care staff generally perceived weaker safety processes than did senior managers, pointing to future targets for interventions to strengthen safety climate.

Relationship Between Working Conditions, Worker Outcomes, and Patient Care: A Theoretical Model for Frontline Health Care Workers

Despite the integral role that frontline health care workers play in providing care to older adults and those with chronic conditions and disabilities, few studies have examined the relationships between the working conditions endured by this workforce, the quality of the care they deliver, and the outcomes of patients for whom they care. Thus, the authors: (1) developed a novel conceptual framework that highlights these relationships and (2) performed a comprehensive search and analysis of the literature (PubMed, AgeLine, Cumulative Index to Nursing and Allied Health Literature (CINAHL), JSTOR, Scopus, Web of Science) to assess the relationships proposed in the framework. A total of 31 studies were included. The results suggest that working conditions affect workers themselves, the care they deliver, and their patients' outcomes. Additional studies, as well as policy solutions, are needed to address the issues faced by this workforce in order to improve health care delivery.

A cross-sectional study of implicit rationing of care in publicly funded nursing homes in Shanghai, China

AIMS

To investigate the level of implicit care rationing and its association with training needs in nursing homes in Shanghai, China.

BACKGROUND

Nursing homes in Shanghai are confronted with a lack of care resources. Implicit care rationing can emerge due to inadequate training of care workers.

METHODS

A cross-sectional survey was conducted between 10 September and 17 November 2020. A total of 374 care workers from 16 randomly were selected nursing homes from each of the administrative districts participated the surveys. The Basel Extent of Rationing of Nursing Care-Nursing Home instrument and the training needs analysis were adopted to measure implicit care rationing and training needs, respectively. Multiple regression techniques were used to explore the factors associated with implicit care rationing.

RESULTS

Activities related to social care, documentation and activation/rehabilitation (mean rating = 2.8, 1.89 and 1.93 respectively) were mostly likely to be rationed. Training needs of activities of daily living (ADL), activation/rehabilitation and documentation were significantly related to their implicit rationing (β = 0.864, 0.21 and 0.166, respectively, p < .01).

CONCLUSION

Training needs are crucial determinants of implicit care rationing.

IMPLICATIONS FOR NURSING MANAGEMENT

Quality control systems are needed to ensure care comprehensiveness. The current training system should be re-designed according to results of training needs analysis.

Level of anxiety symptoms and its associated factors among nurses working in emergency and intensive care unit at public hospitals in Addis Ababa, Ethiopia

Background

Anxiety is a common phenomenon in some professions including medical emergency settings. Nurses deal with grief and other psychological disturbances when they lost clients due to death at clinical settings. Thus, the level of anxiety among nurses working at emergency and intensive care unit is expected to higher as a result of life threatening cases and frequent loss of clients at emergency settings. However, the burden of anxiety and its associated factors among nurses working in emergency clinical settings are not well addressed in Ethiopia.

Methods

An institutional based cross-sectional study design was conducted among 415 randomly selected nurses working at emergency and Intensive Care Unit at public hospitals in Addis Ababa. Data were collected using interviewer administered questioner. The Hamilton Anxiety Rating Scale was used to measure level of anxiety symptoms. The collected data were entered to a computer using Epi-Data Version 3.1 and exported to SPSS Version 20.0 for analysis. Binary logistic regression was used to identify factors associated with anxiety. Variables with P- Values of < 0.05 were considered as having statistically significant association with higher level of anxiety symptoms with 95 % confidence intervals.

Results

The result of this study shows that 19.8 % nurses working at emergency and intensive care unit had a higher level of anxiety symptoms [95 % CI (16.1 %- 23.6 %)]. Marital status{0.28:95 %CI(0.16–0.50)}, cigarette smoking{2.48:95 %CI(1.18–5.18)}, work overload {0.35:95 %CI(0.16,0.76)} and night duty shift{0.41:95 %CI(0.19–0.87)} were factors significantly associated with higher level of anxiety symptoms among nurses working at emergency medical settings.

Conclusions

Nurses working at emergency and intensive care unit showed higher level of anxiety symptoms than the general population and nurses working at other medical settings. Marital status, cigarette smoking, work overload and night duty shift had statistically significant association with higher anxiety symptoms among nurses working at emergency medical settings. This demonstrates a need for the implementation of counseling services regarding effective coping mechanisms and problem-solving strategies for nurses working at emergency medical settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00701-4.

Residents' and Relatives' Experiences of Acute Situations: A Qualitative Study to Inform a Care Model

Background and Objectives

As new models of care aiming to reduce hospitalizations from nursing homes emerge, their implementers must consider residents’ and relatives’ needs and experiences with acute changes in the residents’ health situations. As part of the larger INTERCARE implementation study, we explored these persons’ experiences of acute situations in Swiss nursing homes.

Research Design and Methods

3 focus groups were conducted with residents and their relatives and analyzed via reflexive thematic analysis.

Results

The first theme, the orchestra plays its standards, describes experiences of structured everyday care in nursing homes, which functions well despite limited professional and competency resources. The second theme, the orchestra reaches its limits, illustrates accounts of acute situations in which resources were insufficient to meet residents’ needs. Interestingly, participants’ perceptions of acute situations went well beyond our own professional view, that is, changes in health situations, and included situations best summarized as “changes that might have negative consequences for residents if not handled adequately by care workers.” Within the third theme, the audience compensates for the orchestra’s limitations, participants’ strategies to cope with resource limitations in acute situations are summarized.

Discussion and Implications

Our findings suggest differences between care providers’ and participants’ perspectives regarding acute situations and care priority setting. Alongside efforts to promote staff awareness of and responsiveness to acute situations, care staff must commit to learning and meeting individual residents’ and relatives’ needs. Implications for the development and implementation of a new nurse-led model of care are discussed.

Licenced practical nurses' perceptions of their work environments and their intention to stay: A cross-sectional study of four practice settings

Aims and objectives

This study aimed to understand how licenced practical nurses perceive their work environments across different work settings and to analyse the association between these nurses’ perceptions of their work environments and their intentions to stay employed at their current nursing unit.

Design

A cross‐sectional descriptive survey was conducted with Licensed Practical Nurses in Alberta, Canada.

Methods

The study population consisted of 598 licenced practical nurses. Survey measures included demographic information, the Perceived Work Environment‐Nursing Work Index, and an intention to stay scale. Descriptive statistics were calculated and mean scores for perceptions about the work environment were compared by work setting. The associations between perceived work environment and intention to stay were analysed using linear regression.

Results

Overall, licenced practical nurses rated their work environment as mixed, with statistically significantly lower scores in acute care settings. Nurse manager ability and adequate staffing and resources were the highest contributing variables.

The relationship between quality and staffing in long-term care: A systematic review of the literature 2008-2020

BACKGROUND

Higher staffing levels in long-term care have been associated with better outcomes for residents in several landmark studies. However previous systematic reviews found mixed results, calling into question the effectiveness of higher levels of staff. With persistent concerns about quality, rising resident acuity, and a growing demographic of seniors requiring more services, understanding the relationship between quality and long-term care staffing is a growing concern.

OBJECTIVES

This review considered the following question: What is the influence of nursing and personal care staffing levels (registered nurse, licensed practical nurse, and nursing assistant) and / or skill mix on long-term care residents, measured by quality of care indicators?

DESIGN

Preferred Reporting Items for Systematic Review and Meta-analysis Protocols guided the report of this systematic review.

DATA SOURCES

Published articles focused on quality and nursing and personal care staffing in long-term care in peer-reviewed databases (MEDLINE, CINAHL, and AGELINE) and several Cochrane databases to retrieve studies published between January 2008 and June 2020.

REVIEW METHODS

A systematic review was conducted. 11,096 studies were identified, of which 34 were included in this review. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used to evaluate study quality and risk of bias, and five quality measures were selected for in-depth analyses: pressure ulcers, hospitalizations, physical restraints, deficiencies and catherization.

RESULTS

This review confirms previous review findings that evidence on the relationships between quality and long-term care staffing level and skill mix, remain mixed. Higher staffing levels and skill mix generally supported better rather than worse outcomes. Significant and consistent findings were more evident when staffing levels were further analyzed by indicator and staffing category. For example, registered nurses were consistently associated with significantly fewer pressure ulcers, hospitalizations, and urinary tract infections. Few studies examined the impact of total nursing and personal care hours compared to the impact of specific categories or classes of nursing staff on outcomes.

CONCLUSIONS

Evidence on the relationship between quality and long-term care staffing remains mixed, however some categories of nursing staff may be more effective at improving the quality of certain indicators. Study quality has improved minimally over the last decade. Although research continues to standardize units of measurement, and longitudinal and instrumental variable analyses are increasingly being used, very few studies controlled for endogeneity, conducted adequate risk-adjustment, and used resident-level data. Additional strides must still be made to improve the rigor of long-term care staffing research.

Impact of fatigue on nursing care rationing in paediatric haematology and oncology departments - a cross-sectional study

Background

Rationing of nursing care is a relatively new concept. It refers to an error of omission and has a direct influence on the quality of nursing care and treatment outcomes. Nurses who experience chronic fatigue often fail to perform their duties properly, which may lead, for instance, to medical errors attributed to impaired judgment. Therefore, it is necessary to identify factors which give rise to fatigue, leading to rationing of nursing care, and develop strategies to eliminate them. The primary objective of the study was to assess the impact of fatigue on nursing care rationing in paediatric haematology and oncology departments. The secondary objective of this study was to identify the factors, which may influence the nursing care rationing.

Methods

The study was conducted among 95 nurses (aged between 23 and 58 years) workinginthe Department of Paediatric Oncology, Haematology and Bone Marrow Transplantation of the University Teaching Hospital in Wroclaw. Participation in the study was voluntary and anonymous. Our own sociodemographic questionnaire, the Basel Extent of Rationing of Nursing Carequestionnaire and the modified fatigue impact scale (MFIS) were used in the study.

Results

The level of fatigue among the nurses participating in the study, as measured by the MFIS, was high, namely 28.97 ± 16.78. It was found that the fatigue of the nurses influenced most often the psycho-social dimension of QoL (1.78 ± 1.05), and least often - cognitive (1.24 ± 0.78). A correlation analysis showed that all aspects of fatigue had a statistically significant positive impact on care rationing (p < 0.05), i.e. the greater the fatigue, the higher the level of care rationing. A regression analysis showed that a 12-h shift pattern was an independent predictor of the level of care rationing (r = 0.771, p < 0.05).

Conclusions

Nurses working in paediatric haematology departments report a high level of fatigue. Work pattern is an independent determinant of nursing carerationing. A high level of nursing care rationing was found for nurses working 12-h shifts.

Trial registration

The study was approved by the Bioethics Committee of the Wroclaw Medical University, Poland (February 8th 2019, No. 205/2019).

Not Just How Many but Who Is on Shift: The Impact of Workplace Incivility and Bullying on Care Delivery in Nursing Homes

BACKGROUND AND OBJECTIVES

Much of the literature examining the staffing-care quality link in long-term care (LTC) homes focuses on staffing ratios; that is, how many staff are on shift. Far less attention is devoted to exploring the impact of staff members' workplace relationships, or who is on shift. As part of our work exploring workplace incivility and bullying among residential care aides (RCAs), we examined how RCAs' workplace relationships are shaped by peer incivility and bullying and the impact on care delivery.

RESEARCH DESIGN AND METHODS

Using critical ethnography, we conducted 100 hr of participant observation and 33 semistructured interviews with RCAs, licensed practical nurses, support staff, and management in 2 nonprofit LTC homes in British Columbia, Canada.

RESULTS

Three key themes illustrate the power relations underpinning RCAs' encounters with incivility and bullying that, in turn, shaped care delivery. Requesting Help highlights how exposure to incivility and bullying made RCAs reluctant to seek help from their coworkers. Receiving Help focuses on how power relations and notions of worthiness and reciprocity impacted RCAs' receipt of help from coworkers. Resisting Help/ing outlines how workplace relationships imbued with power relations led some RCAs to refuse assistance from their coworkers, led longer-tenured RCAs to resist helping newer RCAs, and dictated the extent to which RCAs provided care to residents for whom another RCA was responsible.

DISCUSSION AND IMPLICATIONS

Findings highlight "who" is on shift warrants as much attention as "how many" are on shift, offering additional insight into the staffing-care quality link.

A scoping review-Missed nursing care in community healthcare contexts and how it is measured

Aim

To examine the extent and nature of missed nursing care in elderly care in community healthcare contexts from the perspective of healthcare staff, and to identify instruments used to measure missed nursing care and the content of these instruments.

Design

Scoping review.

Methods

Searches were conducted in the CINAHL, PubMed, Scopus and Google Scholar databases in March 2020. The selection process followed the PRISMA flow diagram.

Results

Sixteen research papers were found from nine countries. The instruments used in the studies were Basel Extent of Rationing of Nursing Care for nursing homes (BERNCA‐NH), modified MISSCARE survey and study‐specific instruments or items. The item content differed, as did the number of items, which was between one and 44. The studies reported values for missed nursing care, as well as described reasons for and/or the relation between missed nursing care and organization, working climate and patient outcomes.

Authentic leadership, nurse-assessed adverse patient events and quality of care: The mediating role of nurses' safety actions

BACKGROUND

Authentic leadership has been consistently cited as a strong precursor of sustained job performance and work effectiveness in nurses; however, studies linking authentic leadership with nurses' safety actions, nurse-assessed adverse patient events and nursing care quality are scarce.

AIM

To examine whether nurses' safety actions mediate the relationship between authentic leadership, nurse-assessed adverse events and nursing care quality.

METHODS

A multi-centre, cross-sectional study involving 1,608 nurses employed in acute care facilities in Oman. Multi-stage regression analysis was conducted in testing for the mediation model.

FINDINGS

Nurse managers in Oman were perceived to be highly authentic by their staff nurses. Authentic leadership significantly predicted nurses' safety actions (β = 0.168, p < .001), decrease in nurse-assessed adverse events (β = -0.017, p = .024) and increase in care quality (β = 0.121, p < .001). Further, the association between authentic leadership and nurse-assessed adverse events (β = -0.063, p = .057) and care quality (β = 0.038, p = .002) was mediated by nurses' safety actions.

CONCLUSION

Results suggest the importance of developing nurse managers' authentic leadership to foster nurses' safety actions and reduce adverse patient outcomes and promote nursing care quality.

IMPLICATIONS FOR NURSING MANAGEMENT

Organizational efforts to address patient safety issues should be directed towards developing authentic leadership in nurse managers through leadership programmes, periodic evaluation of leadership competencies (e.g., 360-degree or a bottom-up performance evaluation), and a creation of a safe culture in which nurses can openly report safety concerns for corrective action.

Unfinished Care in Residential Aged Care Facilities: An Integrative Review

BACKGROUND AND OBJECTIVES

When workload demands are greater than available time and resources, staff members must prioritize care by degree of importance and urgency. Care tasks assigned a lower priority may be missed, rationed, or delayed; collectively referred to as "unfinished care." Residential aged care facilities (RACFs) are susceptible to unfinished care due to consumers' complex needs, workforce composition, and constraints placed on resource availability. The objectives of this integrative review were to investigate the current state of knowledge of unfinished care in RACFs and to identify knowledge gaps.

RESEARCH DESIGN AND METHODS

We conducted a search of academic databases and included English-language, peer-reviewed, empirical journal articles that discussed unfinished care in RACFs. Data were synthesized using mind mapping techniques and frequency counts, resulting in two categorization frameworks.

RESULTS

We identified 17 core studies and 27 informing studies (n = 44). Across core studies, 32 types of unfinished care were organized under five categories: personal care, mobility, person-centeredness, medical and health care, and general care processes. We classified 50 factors associated with unfinished care under seven categories: staff member characteristics, staff member well-being, resident characteristics, interactions, resources, the work environment, and delivery of care activities.

DISCUSSION AND IMPLICATIONS

This review signifies that unfinished care in RACFs is a diverse concept in terms of types of unfinished care, associated factors, and terminology. Our findings suggest that policymakers and providers could reduce unfinished care by focusing on modifiable factors such as staffing levels. Four key knowledge gaps were identified to direct future research.

Quality of care in Hunan Province nursing homes: relationship to staffing and organizational climate

Our objective was to examine the quality of care perceived by nursing staff and its relationship with the staffing and organizational climate in nursing homes. The participants in this cross-sectional study included 358 nursing staff from 26 nursing homes in Hunan Province, China. This study found that the interaction effect between nursing staff to resident ratio and physician to resident ratio exerted a significant effect on quality of care (p < 0.05). Higher scores on the relationships and communication scale (OR = 4.771, p = 0.002) and lower scores on the work stress scale (OR = 0.980, p = 0.050) were also associated with better quality of care. More work experience was related to lower quality of care (OR = 0.944, p = 0.048), and work experience was associated with relationships and communication (Beta = 0.172, p = 0.002) and work stress (Beta= = 0.259, p = 0.000). Staffing level, work experience, work stress, relationships and communication are key factors in providing higher quality of care in nursing homes.

Electronic Health Record Use in Swiss Nursing Homes and Its Association With Implicit Rationing of Nursing Care Documentation: Multicenter Cross-sectional Survey Study

BACKGROUND

Nursing homes (NHs) are increasingly implementing electronic health records (EHRs); however, little information is available on EHR use in NH settings. It remains unclear how care workers perceive its safety, quality, and efficiency, and whether EHR use might ease the burden of documentation, thereby reducing its implicit rationing.

OBJECTIVE

This study aims to describe nurses' perceptions regarding the usefulness of the EHR system and whether sufficient numbers of computers are available in Swiss NHs, and to explore the system's association with implicit rationing of nursing care documentation.

METHODS

This was a multicenter cross-sectional study using survey data from the Swiss Nursing Homes Human Resources Project 2018. It includes a convenience sample of 107 NHs, 302 care units, and 1975 care workers (ie, registered nurses and licensed practical nurses) from Switzerland's German- and French-speaking regions. Care workers completed questionnaires assessing the level of implicit rationing of nursing care documentation, their perceptions of the EHR system's usefulness and of how sufficient the number of available computers was, staffing and resource adequacy, leadership ability, and teamwork and safety climate. For analysis, we applied generalized linear mixed models, including individual-level nurse survey data and data on unit and facility characteristics.

RESULTS

Overall, the care workers perceived the EHR systems as useful; ratings ranged from 69.42% (1362/1962; guarantees safe care and treatment) to 78.32% (1535/1960; allows quick access to relevant information on the residents). However, less than half (914/1961, 46.61%) of the care workers reported sufficient computers on their unit to allow timely documentation. Half of the care workers responded that they sometimes or often had to ration the documentation of care. After adjusting for work environment factors and safety and teamwork climate, both higher care worker ratings of the EHR system's usefulness (β=-.12; 95% CI -0.17 to -0.06) and sufficient numbers of computers (β=-.09; 95% CI -0.12 to -0.06) were consistently associated with lower implicit rationing of nursing care documentation.

CONCLUSIONS

Both the usefulness of the EHR system and the number of computers available were important explanatory factors for care workers leaving care activities (eg, developing or updating nursing care plans) unfinished. NH managers should carefully select and implement their information technology infrastructure with greater involvement and attention to the needs of their care workers and residents. Further research is needed to develop and implement user-friendly information technology infrastructure in NHs and to evaluate their impact on care processes as well as resident and care worker outcomes.

The role of teamwork in the implicit rationing of nursing care: A systematic mixed-methods review

AIM

To systematically evaluate the role of teamwork in implicit rationing care and how to improve teamwork.

BACKGROUND

The implicit rationing of nursing leads to adverse effects for both patients and nurses. Therefore, how to reduce it has attracted increasing research attention. How teamwork may be an important factor in reducing implicit rationing care has become a focus of research.

METHODS

Data between May 2000 and May 2020 were collected from five databases. The study was guided by the framework of a mixed studies review.

RESULTS

Seventeen studies were chosen for review regarding efficient teamwork to reduce implicit rationing care. The following seven subthemes with positive effects that improve teamwork and reduce implicit rationing care were formed: (a) improving knowledge and skills; (b) promoting effective communication; (c) building mutual trust; (d) reducing turnover intention; (e) reasonable staffing; (f) division of responsibilities; and (g) cultivating team consciousness.

CONCLUSIONS

Teamwork can decrease implicit care and is influenced by many factors, but the intervention is singular. In the future, teamwork can be further improved to reduce implicit care.

IMPLICATIONS FOR NURSING MANAGEMENT

With more intervention research in the future, leadership and team-oriented roles can be used to complete all the care needed.

Influence of nurse managers' toxic leadership behaviours on nurse-reported adverse events and quality of care

AIM

To assess the impact of toxic leadership behaviours among nurse managers on nurse-reported adverse events and quality of care.

BACKGROUND

Toxic leadership, a form of ineffective leadership, is increasingly becoming rampant in the field of nursing and has been strongly linked to poor nurse job outcomes including job dissatisfaction, higher stress levels, and increased turnover intention. To date, no studies have been conducted to examine how this type of leadership behaviours affects patient outcomes and care quality.

METHODS

A multicentre, cross-sectional study. This study involved a sample of 1,053 registered nurses working in 20 hospitals in the Philippines. Three standardized scales were deployed, including the Toxic Leadership Behaviors of Nurse Managers Scale, the Adverse Patient Events Scale and the single-item quality-of-care-measure.

RESULTS

Overall, nurses (96.2%) appraised the quality of care of their respective units as 'good to excellent' and cited complaints from patients and their families as the most commonly reported adverse events. Toxic leadership behaviours in nurse managers were strongly associated with increased nurse-reported adverse events including reports of complaints (β = .619; p < .001) and verbal mistreatment from patients and their families (β = .407; p < .001), patient falls (β = .834; p < .001), health care-associated infections (β = .629; p < .001) and errors in administering medication (β = .708; p < .001) and with decreased quality of care (β = -.216; p < .001).

CONCLUSION

Nurses who experience working under a nurse manager exhibiting toxic behaviours reported an increased frequency of nurse-reported adverse events and poorer quality of care in the unit.

IMPLICATIONS FOR NURSING MANAGEMENT

Organizational measure to reduce the occurrence of adverse events and enhance the quality of care provided in medical units may include intervention to develop positive leadership practices among nurse managers.

Leadership styles and leadership outcomes in nursing homes: a cross-sectional analysis

Background

Although leadership is considered as a key factor in health care, leadership styles and outcomes in nursing homes often remain a black box. Therefore, this study explored leadership styles and leadership outcomes of head nurses and directors of nursing (DoN) in nursing homes based on well-defined leadership concepts.

Methods

A multicenter cross-sectional analysis was conducted on baseline data of an ongoing cohort study comprising a convenience sample of nursing home staff (n = 302). Leadership styles and leadership outcomes of head nurses and DoN were measured through the rater form of the Multifactor Leadership Questionnaire 5X (MLQ-5X). Based on the Full Range of Leadership Model, the MLQ-5X visualizes transformational (relation and change focused), transactional (task-focused) and passive-avoidant (absence of leadership) leadership styles. Scores of head nurses and DoN for leadership styles and outcomes were compared with European Reference Scores (ERS) using two-sided one-sample t-tests.

Results

Compared with ERS, head nurses and DoN scored significantly lower (p < 0.001) on transformational and transactional leadership styles and significantly higher (p < 0.001) on passive-avoidant leadership styles. All leadership outcomes were significantly lower (p < 0.001) for head nurses. Similar results, however not statistically significant, were found concerning leadership outcomes of DoN.

Conclusions

Results indicate that passive-avoidant leadership styles are excessively present in contrast to transformational leadership styles in nursing homes. This highlights an urgent need to invest in leadership development. Therefore, future research should focus on interventions for the development of transformational leadership.

Interventions to prevent or reduce rationing or missed nursing care: A scoping review

AIMS

To collate and synthesize published research on interventions developed and tested to prevent or reduce the rates of rationed or missed nursing care in healthcare institutions.

BACKGROUND

Rationed and missed nursing care has been widely studied, including its predictors and associations with patient and nurse outcomes.

DESIGN

Scoping review.

DATA SOURCES

We searched for eligible studies, published between 1980-2019, in six electronic databases.

REVIEW METHODS

Researchers independently screened the abstracts of the retrieved studies using the inclusion and exclusion criteria. The decision of whether or not to include any given study was consensus-based.

RESULTS

The search yielded 1,815 records, of which 13 were included. Three studies reported structural interventions, namely increased nurse staffing and improved nursing teamwork, both resulted in significant reductions in the rates of rationed or missed nursing care. The remaining 10 studies reported on process interventions: four concerned reminders (via technology or designated persons) and seven described interventions to change or optimize the relevant care processes. All 10 process interventions contributed to significant reductions in the rates of missed nursing care.

CONCLUSIONS

The results of the scoping review indicate that specific interventions can positively influence the performance of a selected nursing care activity, for example fall prevention. There is no evidence of a global reduction of rationed and missed nursing care through these interventions.

IMPACT

Clinicians, managers and researchers can use the results for adapting and implementing interventions to reduce rationed and missed nursing care.

Using the Delphi Method to Identify Risk Factors Contributing to Adverse Events in Residential Aged Care Facilities

Purpose

This study aimed to identify risk factors associated with adverse events in residential aged care facilities in China.

Patients and Methods

After compiling a list of risk factors for adverse events generated from in-depth interviews with managers of residential aged care facilities, a three-round Delphi method was used to reach consensus. The synthesized risk factors were presented on a Likert scale to the expert panelists three times to validate their responses.

Results

The list identified 67 items as risk factors for adverse events, attached to four first-level indexes (ie, environmental facility, nursing staff, older adults' characteristics, and management factors). The experts' authority coefficient was 0.87. The positive coefficients were 82.76%, 91.67%, and 100%, and the coordination coefficients were 0.154, 0.297, and 0.313 in the first, second, and third rounds, respectively.

Conclusion

Using a Delphi method, this study established a consensus on risk factors contributing to adverse events and developed a risk assessment grade for use in future aged care practice and research. The resulting list is useful in prioritizing risk-reduction activities and assessing intervention or education strategies for preventing adverse events in residential aged care facilities.

Impact

This study fills the gap in risk identification in the Chinese residential aged care system to ensure provision of best-practice care to this vulnerable population. Nursing staff and management factors at the top of the list are not only the most common causes of adverse events but also the core elements in creating a secure and error-free environment. This list was intended to support predictive and prevention-oriented decision-making by managers and nursing supervisors to reduce preventable adverse events.

Gender-Specific Aspects of Health Literacy: Perceptions of Interactions with Migrants among Health Care Providers in Germany

Health literacy can be described as a complex process shaped by individual resources and preferences and by the nature and quality of health-related information people encounter. The main objective of this study was to explore the views of health care professionals on how gender as a personal determinant of health literacy affected their interactions with migrant patients. The interrelated challenges, needs and applied solutions were analyzed from a health literacy perspective. Five focus group discussions with health care professionals working with migrants (n = 31) were conducted in Cologne, Germany, audio recorded, transcribed and analyzed by qualitative content analysis. Gender-specific aspects, such as the gender of health care providers as a factor, were portrayed above all in relation to patients from Turkey and Arab countries regarding access to and understanding of health-related information. These statements exclusively represent the possibly biased or assumptions-based perspectives of health care professionals on their migrant patients and were made against the background of a systemic lack of time and the challenge of overcoming language barriers. Especially in this context, reducing time pressure and improving communication in the treatment setting may be to the benefit of all actors within healthcare.

Support workers' experiences of work stress in long-term care settings: a qualitative study

Background: Support-workers’ performance and well-being are challenged by increasingly high workloads and poor working conditions, leading to high levels of occupational stress.

Aims: To explore the experiences of work stress for support-workers in New Zealand residential facilities.

Design: An Interpretive Descriptive study.

Methods: Data from ten (n = 10) support-workers were collected between December 2013 and June 2014, using semi-structured in-depth face-to-face interviews. Thematic analysis was used to identify key themes that captured participant reports of their experiences.

Results: Work stress was conceptualized by participants as being an everyday experience of having too much to deal with and feeling under constant pressure. It appeared to be a complex and fluid experience representing an inherent, dynamic tension between reasons to be a caregiver and the burden of caregiving. Participants highlighted a range of influencing factors (including lack of recognition, person and work context, and coping strategies), which may account for that fluidity.

Conclusion: The findings extend current knowledge about support-workers’ work stress by identifying the challenges relating to the lack of recognition of their role and expertize, the unintended consequences of person-centered care and the challenges faced by migrant support-workers.

Adaptation, modification, and psychometric assessment of a Norwegian version of the Basel extent of rationing of nursing care for nursing homes instrument (BERNCA-NH)

Background

To our knowledge, no instrument has been developed and tested for measuring unfinished care in Norwegian nursing home settings. The Basel Extent of Rationing of Nursing Care for Nursing Homes instrument (BERNCA-NH) was developed and validated in Switzerland to measure the extent of implicit rationing of nursing care in nursing homes. The BERNCA-NH comprises a list of nursing care activities in which a care worker reports the frequency to which activities were left unfinished over the last 7 working days as a result of lack of time. The aim of this study was to adapt and modify a Norwegian version of the BERNCA-NH intended for all care workers, and assess the instruments’ psychometric properties in a Norwegian nursing home setting.

Methods

The BERNCA-NH was translated into Norwegian and modified to fit the Norwegian setting with inputs from individual cognitive interviews with informants from the target population. The instrument was then tested in a web-based survey with a final sample of 931 care workers in 162 nursing home units in different parts of Norway. The psychometric evaluation included score distribution, response completeness and confirmatory factor analysis (CFA) of a hypothesised factor structure and evaluation of internal consistency. Hypothesised relation to other variables was assessed through correlations between the subscale scores and three global ratings.

Results

The Norwegian version of BERNCA-NH comprised four subscales labelled: routine care, ‘when required’ care, documentation and psychosocial care. All subscales demonstrated good internal consistency. The CFA supported the four-factor structure with fit statistics indicating a robust model. There were moderate to strong bivariate associations between the BERNCA-NH subscales and the three global ratings. Three items which were not relevant for all care workers were not included in the subscales and treated as single items.

Conclusions

This study found good psychometric properties of the Norwegian version BERNCA-NH, assessed in a sample of care workers in Norwegian nursing homes. The results indicate that the instrument can be used to measure unfinished care in similar settings.

Nursing home work environment, care quality, registered nurse burnout and job dissatisfaction

The objective of this cross-sectional study was to examine the relationships between work environment, care quality, registered nurse (RN) burnout, and job dissatisfaction in nursing homes. We linked 2015 RN4CAST-US nurse survey data with LTCfocus and Nursing Home Compare. The sample included 245 Medicare and Medicaid-certified nursing homes in four states, and 674 of their RN employees. Nursing homes with good vs. poor work environments, had 1.8% fewer residents with pressure ulcers (p = .02) and 16 fewer hospitalizations per 100 residents per year (p = .05). They also had lower antipsychotic use, but the difference was not statistically significant. RNs were one-tenth as likely to report job dissatisfaction (p < .001) and one-eighth as likely to exhibit burnout (p < .001) when employed in good vs. poor work environments. These results suggest that the work environment is an important area to target for interventions to improve care quality and nurse retention in nursing homes.

Registered Nurse Burnout, Job Dissatisfaction, and Missed Care in Nursing Homes

OBJECTIVES

To examine the relationship between registered nurse (RN) burnout, job dissatisfaction, and missed care in nursing homes.

DESIGN

Cross-sectional secondary analysis of linked data from the 2015 RN4CAST-US nurse survey and LTCfocus.

SETTING

A total of 540 Medicare- and Medicaid-certified nursing homes in California, Florida, New Jersey, and Pennsylvania.

PARTICIPANTS

A total of 687 direct care RNs.

MEASUREMENTS

Emotional Exhaustion subscale of the Maslach Burnout Inventory, job dissatisfaction, and missed care.

RESULTS

Across all RNs, 30% exhibited high levels of burnout, 31% were dissatisfied with their job, and 72% reported missing one or more necessary care tasks on their last shift due to lack of time or resources. One in five RNs reported frequently being unable to complete necessary patient care. Controlling for RN and nursing home characteristics, RNs with burnout were five times more likely to leave necessary care undone (odds ratio [OR] = 4.97; 95% confidence interval [CI] = 2.56-9.66) than RNs without burnout. RNs who were dissatisfied were 2.6 times more likely to leave necessary care undone (OR = 2.56; 95% CI = 1.68-3.91) than RNs who were satisfied. Tasks most often left undone were comforting/talking with patients, providing adequate patient surveillance, patient/family teaching, and care planning.

CONCLUSION

Missed nursing care due to inadequate time or resources is common in nursing homes and is associated with RN burnout and job dissatisfaction. Improved work environments with sufficient staff hold promise for improving care and nurse retention. J Am Geriatr Soc 67:2065-2071, 2019.

Factors affecting quality management at the Thai national institute of health

Purpose

The purpose of this paper is to confirm and examine organization-related factors that could affect quality management at the Thai national reference laboratory known as National Institute of Health.

Design/methodology/approach

The authors invited 340 laboratory staff members to complete a questionnaire that enquired about their skills, opinions, perceptions, leadership, work environment, organizational culture and organizational commitment in relation to quality management. Confirmatory factor analysis (CFA) and multiple linear regression were used to analyze the data.

Findings

In total, 65 percent of institute members responded to the questionnaire. CFA revealed that all factors were related to quality management. Three factors, leadership, organizational commitment and work environment, significantly affected quality management, but organizational culture did not.

Research limitations/implications

Other data types should be collected for an in-depth understanding, i.e. focus groups or in-depth interviews. A longitudinal study could also enhance quality management understanding to see how each variable changes over time.

Originality/value

Analyzing quality management through confirmatory factor and regression analysis showed that the four analyzed variables are statistically significant in relation to quality management at the laboratory. Managers could apply this information to revise the current policy.