The Relationship Between Nursing Staff Levels, Skill Mix, and Deficiencies in Maryland Nursing Homes

Determinants of regulatory compliance in health and social care services: A systematic review using the Consolidated Framework for Implementation Research

BACKGROUND

The delivery of high quality care is a fundamental goal for health systems worldwide. One policy tool to ensure quality is the regulation of services by an independent public authority. This systematic review seeks to identify determinants of compliance with such regulation in health and social care services.

METHODS

Searches were carried out on five electronic databases and grey literature sources. Quantitative, qualitative and mixed methods studies were eligible for inclusion. Titles and abstracts were screened by two reviewers independently. Determinants were identified from the included studies, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The quality of included studies was appraised by two reviewers independently. The results were synthesised in a narrative review using the constructs of the CFIR as grouping themes.

RESULTS

The search yielded 7,500 articles for screening, of which 157 were included. Most studies were quantitative designs in nursing home settings and were conducted in the United States. Determinants were largely structural in nature and allocated most frequently to the inner and outer setting domains of the CFIR. The following structural characteristics and compliance were found to be positively associated: smaller facilities (measured by bed capacity); higher nurse-staffing levels; and lower staff turnover. A facility's geographic location and compliance was also associated. It was difficult to make findings in respect of process determinants as qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance.

CONCLUSION

The literature in this field has focused to date on structural attributes of compliant providers, perhaps because these are easier to measure, and has neglected more complex processes around the implementation of regulatory standards. A number of gaps, particularly in terms of qualitative work, are evident in the literature and further research in this area is needed to provide a clearer picture.

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.

Nursing Staff Time and Care Quality in Long-Term Care Facilities: A Systematic Review

BACKGROUND AND OBJECTIVES

In long-term care (LTC) facilities, nursing staff are important contributors to resident care and well-being. Despite this, the relationships between nursing staff coverage, care hours, and quality of resident care in LTC facilities are not well understood and have implications for policy-makers. This systematic review summarizes current evidence on the relationship between nursing staff coverage, care hours, and quality of resident care in LTC facilities.

RESEARCH DESIGN AND METHODS

A structured literature search was conducted using four bibliographic databases and gray literature sources. Abstracts were screened by two independent reviewers using Covidence software. Data from the included studies were summarized using a pretested extraction form. The studies were critically appraised, and their results were synthesized narratively.

RESULTS

The systematic searched yielded 15,842 citations, of which 54 studies (all observational) were included for synthesis. Most studies (n = 53, 98%) investigated the effect of nursing staff time on resident care. Eleven studies addressed minimum care hours and quality of care. One study examined the association between different nursing staff coverage models and resident outcomes. Overall, the quality of the included studies was poor.

DISCUSSION AND IMPLICATIONS

Because the evidence was inconsistent and of low quality, there is uncertainty about the direction and magnitude of the association between nursing staff time and type of coverage on quality of care. More rigorously designed studies are needed to test the effects of different cutoffs of care hours and different nursing coverage models on the quality of resident care in LTC facilities.

Innovation to enhance health in care homes and evaluation of tools for measuring outcomes of care: rapid evidence synthesis

Background

Flexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme.

Aim

To conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation.

Objectives

(1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes?

Data sources

Searches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search.

Design

Mapping review and rapid, systematic evidence syntheses.

Setting

Care homes with and without nursing in high-income countries.

Review methods

Published literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses.

Results

Seven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising.

Limitations

This review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded.

Conclusions

This review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation.

Future work

Future work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context.

Study registration

This study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Factors contributing to serious adverse events in nursing homes

AIMS AND OBJECTIVES

To identify the most common serious adverse events that occurred in nursing homes and their most frequent contributing factors to the improvement of safe nursing care.

BACKGROUND

There is a need to improve safe nursing care in nursing homes. Residents are often frail and vulnerable with extensive needs for nursing care. A relatively minor adverse event in nursing care can cause serious injury that could have been preventable.

DESIGN

This was a retrospective study, with a total sample of data regarding adverse events (n = 173) in nursing homes, concerning nursing care reported by healthcare providers in Sweden to the Health and Social Care Inspectorate. The reports were analysed with content analysis, and the frequencies of the adverse events, and their contributing factors, were described with descriptive statistics.

RESULTS

Medication errors, falls, delayed or inappropriate intervention and missed nursing care contributed to the vast majority (89%) of the serious adverse events. A total of 693 possible contributing factors were identified. The most common contributing factors were (i) lack of competence, (ii) incomplete or lack of documentation, (iii) teamwork failure and (iv) inadequate communication.

CONCLUSIONS

The contributing factors frequently interacted yet they varied between different groups of serious adverse events. The resident's safety depends on the availability of staff's competence as well as adequate documentation about the resident's condition. Lack of competence was underestimated by healthcare providers.

RELEVANCE TO CLINICAL PRACTICE

Registered nurses and assistant nurses need to have awareness of contributing factors to adverse events in nursing care. A holistic approach to improve patient safety in nursing homes requires competence of the staff, safe environments as well as resident's and relative's participation.

Adverse events in nursing: A retrospective study of reports of patient and relative experiences

BACKGROUND

Patient safety is an important global issue. While it is well known that patients can suffer from adverse events in nursing care, there is a lack of knowledge as to how they experience them.

AIM

To examine adverse events in nursing care as they are experienced by patients and relatives.

METHODS

This was a retrospective study taking both a qualitative and a quantitative approach. It was based on data regarding 242 adverse events in nursing care, as reported by patients and relatives to Sweden's Medical Responsibility Board, content analysis was used to analyse the reports.

RESULTS

Patients' and relatives' experiences were analysed into four categories of adverse events, as concerning participation, clinical judgement, nursing intervention and the essentials of care.

LIMITATIONS

The reports were classified by the Medical Responsibility Board, without a standardized system. The adverse events reported were few in number and were reported by patients and relatives only.

CONCLUSION

Lack of participation has negative consequences and contributes to adverse events. Adverse events occur through missed care as well as through carer errors.

IMPLICATIONS ON NURSING AND HEALTH PRACTICE

Nurses need to improve their skills that support patient participation. Patient participation needs to be incorporated into nurses' duties.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Resources for patients to participate in their own care needs to be a priority underpinning policy-making in health systems. Nursing education systems need to teach students about the value and benefits of involving patients in their care.