Effects of nursing practice environments on quality outcomes in nursing homes

Organizational Context and Quality Indicators in Nursing Homes: A Microsystem Look

The association of organizational context with quality of care in nursing homes is not well understood at the clinical microsystem (care unit) level. This cross-sectional study examined the associations of unit-level context with 10 unit-level quality indicators derived from the Minimum Data Set 2.0. Study settings comprised 262 care units within 91 Canadian nursing homes. We assessed context using unit-aggregated care-aide-reported scores on the 10 scales of the Alberta Context Tool. Mixed-effects regression analysis showed that structural resources were negatively associated with antipsychotics use (B = -.06; p = .001) and worsened late-loss activities of daily living (B = -.03, p = .04). Organizational slack in time was negatively associated with worsened pain (B = -.04, p = .01). Social capital was positively associated with delirium symptoms (B = .12, p = .02) and worsened depressive symptoms (B = .10, p = .01). The findings suggested that targeting interventions to modifiable contextual elements and unit-level quality improvement will be promising.

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.

A Cross-sectional Study Evaluating the Association Between the Nursing Practice Environment and Missed Nursing Care in Medical and Surgical Wards in Jordan

BACKGROUND

Missed nursing care can jeopardize the safety of patients. The practice environment contains various elements that may impact nursing staff's capability to provide appropriate care.

PURPOSE

To examine the association between the practice environment and missed nursing care in Jordanian hospitals.

METHODS

A cross-sectional design, including the MISSCARE survey and the Practice Environment Scale of the Nursing Work Index, was used for this study.

RESULTS

Data were gathered from 672 nurses working in 10 hospitals between March and July 2021. Findings revealed significant negative correlations between nurses' participation in hospital affairs ( r = -0.077, P = .046), nursing foundations for quality of care ( r = -0.139, P < .001), and missed nursing care.

CONCLUSION

Information from this study can help nursing leaders modify practice environment elements that impact missed nursing care occurrences, which will help improve the quality of care provided to patients.

An organizational design perspective on the monthly self-scheduling process in nursing homes: A multiple case study

AIMS

To describe the monthly self-scheduling process in nursing homes (NH), to determine how specific organizational design characteristics (including interpersonal relationships and leadership style) influence this process, and to examine the effect on individual, team, and organization-related outcomes.

DESIGN

A multiple case study using an organizational design perspective as the overarching theoretical and explanatory framework.

METHODS

Data collection was performed in four Belgian NH during Spring 2019 using semi-structured interviews (n = 39), documents, and observations. Open, axial, and selective coding was used for the data reduction process, and a within-case and cross-case analysis was performed. The COREQ checklist was used for reporting the findings.

RESULTS

One group (two NH) used self-scheduling because it corresponds with their decentralized organizational design. Together with a motivating head nurse and additional resources during the core phase of the process, this led to positive outcomes. In contrast, another group used self-scheduling under the assumption that it would solve the mismatch between their organizational design and other organizational problems, which resulted in less positive work attitudes.

CONCLUSION

Self-scheduling should match the organizational structure and culture. Additional resources and an adaptive leadership style can help mobilize and support employees. Future research may use quantitative methods to confirm positive outcomes.

IMPACT

This study contributes to the rare literature on self-scheduling in NHs by focusing on the monthly self-scheduling process and by including an organizational design perspective. NH management can become informed of different self-scheduling methodologies and the impact of specific organizational characteristics on this process. Head nurses can become aware that they need to adapt their leadership style to obtain improved outcomes.

PATIENT OR PUBLIC CONTRIBUTION

Three members of the study team met with several caregivers during field visits to conduct interviews and to observe the monthly self-scheduling process.

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.

Professional development and career planning for nurses working in care homes for older people: A scoping review

BACKGROUND

A skilled, knowledgeable, and compassionate nurse workforce is pivotal to caring well for older people living in care homes. This requires the provision of continuing professional development and career planning for nurses, which are key also for nurse recruitment and retention. Continuing professional development and career planning strategies and interventions should be evidence-driven.

OBJECTIVE

To identify the extent, range and nature of contemporary evidence regarding professional development and career planning for nurses caring for older people living in care homes.

METHODS

The methodological framework used was the Joanna Briggs Institute guidance for scoping reviews. The PRISMA extension for scoping reviews was used as the reporting framework. Four databases were searched from January 2010 to July 2021. Results were screened independently by two reviewers using eligibility criteria. Full texts and the reference lists of eligible articles were reviewed. Data were extracted for key elements from the 25 articles included.

RESULTS

Of the 25 articles, the majority were authored in the United States (n = 10) and UK (n = 8) with the remaining from Australia (n = 3), Canada (n = 3) and the Netherlands (n = 1). Four articles reported on professional development programmes. Three literature reviews addressed challenges for nurse participation in professional development, experiences of care home nurses as clinical leaders and managers, and leadership. Two expert commentaries reported on the challenges related to professional development and career planning for care home nurses. Sixteen empirical studies investigated a range of topics including: competencies, roles, intention to stay and leave, continuing professional development, and leadership. Key emergent factors that support professional development and career planning were as follows: access to structured learning opportunities addressing knowledge and skills specific to nursing frail older adults, a supportive working environment including adequate staffing, study time and flexible working, and integration of leadership development.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This scoping review has highlighted factors that support and challenge professional development and career planning for nurses working in the care home sector. There remain important gaps in the opportunities for professional development and career planning for care home nurses that warrant attention.

Effects of Nurse Staffing on Resident Outcomes in Nursing Homes: A Systematic Review

OBJECTIVES

To evaluate the evidence on effects of nurse staffing in nursing homes on resident outcomes.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Studies evaluating the effects of nurse staffing levels, total staffing, or skill mix on pressure ulcers, nursing home associated infections, and pain outcomes for adult residents in US nursing homes.

METHODS

We searched MEDLINE, Embase, CINAHL, and the Cochrane Database for English-language articles published between January 2000 and May 2021. We also searched for gray literature and sought expert referrals. Two reviewers participated in determination of eligibility, assessment of methodological quality, and abstraction of data. Abstracted data included study design; setting and population characteristics; and resident outcomes. We rated overall certainty of evidence (very low, low, moderate, and high) for each outcome using GRADE.

RESULTS

Of 9152 unique citations, 378 articles underwent full-text review. We identified 22 eligible studies that addressed pressure ulcers (k = 15), COVID-19 cases and/or mortality (k = 4), other infections (k = 8), and moderate-severe pain among residents (k = 7); some examined multiple outcomes. Most studies (k = 17) were rated moderate or high quality. All studies were observational. Overall, registered nurse (RN) staffing was probably associated with fewer pressure ulcers (moderate certainty) and possibly fewer COVID-19 infections/mortality (low certainty), other infections (low certainty) and lower rates of moderate-severe pain (low certainty). Higher skill mix was probably associated with fewer pressure ulcers, higher resident COVID-19 infections, fewer other infections, and lower rates of moderate-severe pain (low certainty for all outcomes).

CONCLUSIONS AND IMPLICATIONS

Higher RN staffing and skill mix may be associated with better nursing home resident outcomes, while results were mixed for total staffing. Increasing RN staffing levels and skill mix are one of a variety of approaches to improve nursing home care.

Vicarious Trauma Experienced by Health Care Providers Involved in Traumatic Childbirths: A Meta-Synthesis

Health care providers are often "second victims" of traumatic childbirth events and should be adequately supported by their organizations to alleviate occupational stress and burnout. Therefore, this review aimed to explore and understand the vicarious traumatic childbirth experiences of health care providers, including obstetricians, midwives, nurses, and students. A systematic review of qualitative studies was conducted. Seven electronic databases, namely, PubMed, CINAHL, Embase, PsycINFO, Cochrane, Scopus, and Web of Science, were searched from each database's inception to May 2020. In total, 1,575 studies were retrieved and screened according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Seventeen studies were included in this review and were meta-summarized and then meta-synthesized using the Sandelowski and Barroso approach. The overarching theme of "Tunneling through the trauma with a hope of finding an end" was derived, and four main themes along with 15 subthemes were identified. The four main themes were (1) "instantaneous response to the trauma," (2) "finding hope in the midst of chaos," (3) "dealing with the aftermath," and (4) "resolution to move on." Communication and teamwork among health care team members were identified as challenges contributed by professional hierarchy and lack of role clarity. Midwives and labor and delivery nurses expressed powerlessness in advocating for women on many occasions, and health care providers often had feelings of guilt and self-blame after adverse events. Health care providers also reported inadequate support from their colleagues and organizations, which influenced their ability to cope with the aftermath of trauma and their decision to stay in the profession.

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.

The Development and Validation of a Communication Survey Instrument for Long-term Care Staff

Information transfers in long-term care (LTC) settings between and among providers, staff, residents, and family caregivers are often fragmented. In order to identify training needs to improve communication, a survey instrument was developed and refined to assess the self-efficacy of LTC staff in communicating with staff, providers, residents, and caregivers. This 11-item survey instrument, based on a literature review, covered four key concepts (mutual respect, recognizing and responding to sensory deficits, limited health literacy, and changes in condition) relevant to communicating health information in LTC settings. Ten content experts evaluated each survey item using a 4-point scale. The content validity of the survey was established by using the content validity index to assess results at the item and scale levels. All items scored 0.90 or greater and were retained. Future work should entail broad-scale validation and testing of this survey across the United States. By assessing the self-efficacy of LTC staff in communicating with the interprofessional team, leadership teams can design personalized interprofessional continuing education activities aimed at improving communication skills. [J Contin Educ Nurs. 2022;53(3):123-130.].

Effects of registered nurse staffing levels, work environment, and education levels on adverse events in nursing homes

This study examined the effects of nurse staffing levels, work environment, and education levels on adverse events in nursing homes. A cross-sectional study was conducted involving 216 nurses working in 62 nursing homes in South Korea, using self-reported questionnaires and data from the National Health Insurance Service of South Korea. A logistic regression model was used to investigate the effects of nurse staffing levels, work environment, and nursing education levels on the adverse events experienced by residents. An increase of one resident per nurse was significantly associated with a higher incidence of medication error, pressure ulcers and urinary tract infections. A poor work environment increased the incidence of adverse events. Compared to nurses with a bachelor’s degree or higher, those with diplomas reported increased incidence rates of pressure ulcers. Improving the health outcomes of residents in nursing homes requires efforts that strengthen the nursing workforce in terms of numbers and educational level, and which improve their work environment at institutional and policy levels.

Perceptions of COVID-19 vaccines among healthcare assistants: A national survey

Background

Limited COVID‐19 vaccination acceptance among healthcare assistants (HCAs) may adversely impact older adults, who are at increased risk for severe COVID‐19 infections. Our study objective was to evaluate the perceptions of COVID‐19 vaccine safety and efficacy in a sample of frontline HCAs, overall and by race and ethnicity.

Methods

An online survey was conducted from December 2020 to January 2021 through national e‐mail listserv and private Facebook page for the National Association of Health Care Assistants. Responses from 155 HCAs, including certified nursing assistants, home health aides, certified medical assistants, and certified medication technicians, were included. A 27‐item survey asked questions about experiences and perceptions of COVID‐19 vaccines, including how confident they were that COVID‐19 vaccines are safe, effective, and adequately tested in people of color. Multivariable regression was used to identify associations with confidence in COVID‐19 vaccines.

Results

We analyzed data from 155 completed responses. Among respondents, 23.9% were black and 8.4% Latino/a. Most respondents worked in the nursing home setting (53.5%), followed by hospitals (12.9%), assisted living (11.6%), and home care (10.3%). Respondents expressed low levels of confidence in COVID‐19 vaccines, with fewer than 40% expressing at least moderate confidence in safety (38.1%), effectiveness (31.0%), or adequate testing in people of color (27.1%). Non‐white respondents reported lower levels of confidence in adequate testing of vaccines compared to white respondents. In bivariate and adjusted models, respondents who gave more favorable scores of organizational leadership at their workplace expressed greater confidence in COVID‐19 vaccines.

Conclusion

Frontline HCAs reported low confidence in COVID‐19 vaccines. Stronger organizational leadership in the workplace appears to be an important factor in influencing HCA's willingness to be vaccinated. Action is needed to enhance COVID‐19 vaccine uptake in this important population with employers playing an important role to build vaccine confidence and trust among employees.

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.

A framework for delivering nursing care to older adults with COVID-19 in nursing homes

Public health emergencies threaten the lives of U.S. citizens, often in disproportionate ways. Hardest hit are vulnerable populations of older adults (OAs) residing in nursing homes (NHs), who comprised nearly 43% of all deaths from COVID-19 in NHs in 2020. New Jersey (NJ) ranks #2 nationally behind New York with the highest numbers of resident deaths; more than 50% of all COVID-19-related deaths in NJ have occurred in NHs. This public health emergency has prompted investigators to evaluate existing structural, resident, process of care, regulatory, and policy characteristics that have impacted the delivery of nursing care within NJ NHs. In this manuscript, we discuss data from NJ NHs during COVID-19, drawing from publicly available data, state reports, and the geriatric literature to offer recommendations. Based on evidence-based practices (EBPs), we present a series of recommendations to modify existing contextual factors in NHs to best prepare for the next health disaster.

A systematic review of the association between nursing staff and nursing-sensitive outcomes in long-term institutional care

AIMS

To examine the association between type of nursing staff and nursing-sensitive outcomes in long-term institutional care.

DESIGN

This systematic review included studies published in English, German, and Dutch between January 1997 and January 2020.

DATA SOURCES

The databases Medline (PubMed), CINAHL, PsycINFO, Embase, and the Cochrane Library were searched. Original quantitative studies were included.

REVIEW METHODS

The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines were followed. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was used to critically appraise the reporting of the studies.

RESULTS

Fifteen articles were included. Of 33 quality of care outcomes, 21 were identified as nursing-sensitive outcomes of which 13 showed a significant association with nursing staff, specifically: Activities of daily living, aggressive behavior, bladder/bowel incontinence, contractures, expressive language skills, falls, infection (including vaccination), range of motion, pain, pressure ulcers, and weight loss. However, studies reported inconsistent results regarding the association among RNs, LPNs, CNAs, and HCAs and these nursing-sensitive outcomes, evidence shows that more RNs have a positive impact on nursing-sensitive outcomes. As to the evidence regarding the other type of nursing staff, especially HCA, findings regularly showed a negative association.

CONCLUSION

Future research should be expanded with structure and process variables of which the mediating and moderating effect on nursing-sensitive outcomes is known. These may explain variances in quality of care and guide quality improvement initiatives. Researchers should consider fully applying Donabedian's structure-process-outcomes framework as it is a coherent entirety for quality assessment.

IMPACT

This review provides an overview of quality of care outcomes that are responsive to nursing interventions in long-term institutional care. As the effects can be monitored and documented, quality assessment should focus on these nursing-sensitive outcomes. The inconclusive results make it difficult to provide recommendations on who should best perform which care.

Prevalence and characteristics of older people with pressure ulcers and legs ulcers, in nursing homes in Barcelona

BACKGROUND

Nursing home residents are vulnerable to chronic wounds. However, the prevalence data are scarce.

AIM

The purpose of this study was to determine the prevalence of pressure ulcers and/or leg ulcers in nursing home residents, and describe the characteristics of the nursing homes, the residents and the wounds, as well as possible associations between these characteristics.

METHODS

This was a cross-sectional survey of nursing home residents over the age of 65 in 168 facilities in Barcelona. Those presenting category II-IV pressure ulcers and/or leg ulcers were included. The data were collected by observation/examination. Descriptive, bivariate, and multivariate analyses were performed.

RESULTS

The overall prevalence of pressure ulcers and leg ulcers combined was 4.4% (3.5% were pressure ulcers and 0.9% were leg ulcers). In small nursing homes with less nursing staff, the overall prevalence was greater than in large nursing homes (5.6% vs 3.8% [p = 0.01]). As expected, residents with pressure ulcers had higher pressure ulcer risk, worse dependence and cognitive status, urinary and faecal incontinence, and most were underweight. However, residents with leg ulcers had worse venous and arterial impairment and also were overweight. A multivariate analysis showed that pressure ulcers were statistically significantly associated with faecal incontinence (OR = 0.28, 95% CI = 0.09-0.81) and dyslipidaemia (OR = 0.21, 95% CI = 0.06-0.66), and leg ulcers were statistically significantly associated with venous insufficiency (OR = 4.93, 95% CI = 1.65-15.34). The characteristics of gluteal and ischial pressure ulcers, a high prevalence of infection, and a low reference to biofilm by nurses, in both types of wounds, suggest that these aspects are not adequately taken into account.

CONCLUSIONS

Pressure ulcers and leg ulcers, mainly pressure ulcers, remain a public health problem in nursing homes. Further studies are required to confirm the associations found in this study.

Staff Working Life and Older Persons' Satisfaction With Care: A Multilevel, Correlational Design

BACKGROUND

The importance of staff working life for staff well-being has been demonstrated in several studies; less research has focused on staff working life and older persons' satisfaction with care.

PURPOSE

The study aim was to study relationships between 1) staff assessments of their structural conditions/empowerment in elderly care, psychological empowerment, and job satisfaction and (2) older persons' satisfaction with care.

METHODS

A multilevel, cross-sectional, and correlational design was applied using questionnaire data on working life (1021 staff members) and unit-level data (40 elderly care units) on older persons' satisfaction with care.

RESULTS

Statistically significant relationships were found between all 3 working life variables and older persons' satisfaction with care. Furthermore, the results revealed an indirect/mediating effect of job satisfaction between structural empowerment and satisfaction with care, but not for psychological empowerment.

CONCLUSIONS

Staff structural empowerment, psychological empowerment, and job satisfaction are linked to older persons' satisfaction with care.

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.

Which factors are related to Finnish home care workers' job satisfaction, stress, psychological distress and perceived quality of care? - a mixed method study

BACKGROUND

The desire to increase the role of home care in Finland has created problems in home care work. Working conditions have deteriorated, the quality of care experienced is low, and staff members suffer from time pressure and stress, amongst other things. The aim of this article is to explore the challenges, stressors, teamwork and management factors that are associated with home care staff members' well-being, job satisfaction and experienced care quality, and further, how staff members experience their work.

METHODS

A survey was sent to home care workers in two case organizations that participated in the study. In addition, semi-structured theme interviews with home care workers were conducted. The data from the survey was analysed using analysis of covariance, and interview data was analysed using the Grounded Theory-based method from Gioia et al. RESULTS: Respondents of the survey and the interview participants were mainly female practical nurses. The results from the survey showed, for example, that time pressure was associated with higher stress and psychological distress, and interruptions were associated with lower job satisfaction and higher stress. In addition, variables related to teamwork, such as participative safety, were shown to explain the variation in quality of care. The analysis of the interview data further brought up dissatisfaction with management practices, which seems to have led to a decrease in job satisfaction. Exhaustion and strain were present among staff members, which originated from an insufficient number of carers.

CONCLUSIONS

Current working conditions and work practices in Finnish home care are experienced stressful. The results from this study indicate that having more autonomy at work was associated with job satisfaction, according to both analyses. Team climate and idea implementation were related to quality of care. Therefore, increasing self-organizing team practices might be a possible development method for improving working conditions and staff members' well-being. Implementing self-organizing team practices could possibly also attract employees to work in home care and prevent turnover.

Nursing practice environment in Primary Health Care: a scoping review

OBJECTIVE

To examine the scientific evidence about the nursing practice environment in Primary Health Care.

METHODS

Three-step scoping review. 1) An initial research on CINAHL and MEDLINE. 2) A broader search using the same keywords and search terms in the remaining EBSCOHost platform databases. 3) Search the bibliographical references of the selected articles. The studies selected were from 2007 to 2018.

RESULTS

19 articles were included, most reported findings of the nursing practice environment and results for clients, nurses, nurse managers and the efficiency of organizations, in Primary Health Care.

CONCLUSION

Improving the environment of nursing practice has consequences on the quality of nursing care, with increased results for clients, nursing and Primary Health Care.

Nursing practice environment and care quality in nursing homes

A case study of the Pathway to Excellence in Long-Term Care model.

Effects of a pressure-ulcer audit and feedback regional programme at 1 and 2 years in nursing homes: A prospective longitudinal study

INTRODUCTION

Pressure ulcer is a frequent complication in patients hospitalized in nursing homes and has a serious impact on quality of life and overall health. Moreover, ulcer treatment is highly expensive. Several studies have shown that pressure ulcer prevention is cost-effective. Audit and feedback programmes can help improve professional practices in pressure ulcer prevention and thus reduce their occurrence. The aim of this study was to analyze, with a prospective longitudinal study, the effectiveness of an audit and feedback programme at 1- and 2-year follow-up for reducing pressure ulcer prevalence and enhancing adherence to preventive practices in nursing homes.

METHODS

Pressure ulcer point prevalence and preventive practices were measured in 2015, 2016 and 2017 in nursing homes of the Canton of Geneva (Switzerland). Oral and written feedback was provided 2 months after every survey to nursing home reference nurses.

RESULTS

A total of 27 nursing homes participated in the programme in 2015 and 2016 (4607 patients) and 15 continued in 2017 (1357 patients). Patients were mostly females, with mean age > 86 years and median length of stay about 2 years. The programme significantly improved two preventive measures: patient repositioning and anti-decubitus bed or mattress. It also reduced acquired pressure ulcers prevalence in nursing homes that participated during all 3 years (from 4.5% in 2015 to 2.9% in 2017, p 0.035), especially in those with more patients with pressure ulcers.

CONCLUSION

Audit and feedback is relatively easy to implement at the regional level in nursing homes and can enhance adherence to preventive measures and reduce pressure ulcers prevalence in the homes.

Quality Clinical Care in Nursing Facilities

Despite improvements in selected nursing facility (NF) quality measures such as reduction in antipsychotic use; local, state, and national initiatives; and regulatory incentives, the quality of clinical care delivered in this setting remains inconsistent. Herein, recommendations for overcoming barriers to achieving consistent, high-quality clinical outcomes in long-term (LTC) and post-acute care are provided to address inadequate workforce, suboptimal culture and interprofessional teamwork, insufficiently evidence-based processes of care, and poor adoption and fidelity of technology and integrated clinical decision support. With high staff attrition rates in NFs, mechanisms to measure and close knowledge gaps as well as opportunities for practice simulations should be available to educate and ensure adoption of clinical quality standards on clinician hiring and on an ongoing basis. Multipronged, integrated approaches are needed to further the quest for sustainment of high clinical quality in NF care. In addition to setting a tone for attainment of clinical quality, leadership should champion adoption of practice standards, quality initiatives, and evidence-based guidelines. Maintaining an optimal ratio of hours per resident per day of nurses and nurse aides can improve quality outcomes and staff satisfaction. Clinicians must consistently and effectively apply care processes that include recognition, problem definition, diagnosis, goal identification, intervention, and monitoring resident progress. In order to do so they must have rapid, easy access to necessary tools, including evidence-based standards, algorithms, care plans, during the care delivery process. Embedding such tools into workflow of electronic health records has the potential to improve quality outcomes. On a national and international level, quality standards should be developed by interprofessional LTC experts committed to applying the highest levels of clinical evidence to improve the care of older persons. The standards should be realistic and practical, and basic principles of implementation science must be used to achieve the desired outcomes.

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.

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.

Facilitators and inhibitors of transition for older people who have relocated to a long-term care facility: A systematic review

Moving into a long-term care facility to live permanently is a significant life event for older people. Care facilities need to support older people to make a healthy transition following relocation. To help achieve this, we need to understand what facilitates and inhibits the transition process from the perspective of older people, their families, and care facility staff. Our review generated new knowledge to inform this understanding. We addressed the question: what factors facilitate and inhibit transition for older people who have relocated to a long-term care facility? Five electronic databases, PsychINFO, British Nursing Index, CINAHL, MEDLINE and Web of Science were searched for the period January 1990 to October 2017. Grey literature searches were conducted using Google Scholar, and Social Science Research Network. Data were extracted for individual studies and a narrative synthesis was conducted informed by Meleis's Theory of Transition. Thirty-four studies (25 qualitative, 7 quantitative and 2 mixed methods) met the inclusion criteria. Data synthesis identified that transition following relocation was examined using a variety of terms, timelines and study designs. Potential personal and community focused facilitators and inhibitors mapped to four themes: resilience of the older person, interpersonal connections and relationships, this is my new home, and the care facility as an organisation. These findings can inform the development of interventions for these target areas. They highlight also that further research is warranted to understand the organisational culture of long-term care facilities, how this influences transition, and how it might be shaped to create and sustain a caring culture for older people.

Practice Environment Scale of the Nursing Work Index: A Reliability Generalization Meta-Analysis

A healthy work environment is a critical factor in nurse satisfaction, retention, and patient outcomes. The Practice Environment Scale of the Nursing Work Index (PES-NWI) is the most commonly used instrument to measure the nursing practice environment. This study uses meta-analysis to examine the reliability generalization of the PES-NWI. A meta-analysis of 51 studies representing a total of 80,563 subjects was conducted. The mean score reliability for the PES-NWI based on 38 studies ( n = 68,278) was .922 ( p < .05). The Mean Weighted Effect Size was stronger for studies conducted in the United States versus non-U.S. (.946 vs. .907). For studies rated high and moderate quality, the mean score reliability was .911 and .946, respectively. Scores on the PES-NWI are reliable for measuring the nursing practice environment across samples in the United States and non-U.S. countries.

Development, adaptation and psychometric assessment of the extended brisbane practice environment measure for nursing homes (B-PEM-NH) for use in the Norwegian setting

Care workers' work environment is known to be associated with patient and nurse outcomes. To our knowledge no questionnaire is available for assessing this environment for all care workers in the Norwegian nursing-home setting. This paper describes the development, adaptation and assessment of such a questionnaire: the extended Norwegian version of the Brisbane Practice Environment Measure for Nursing Homes (B-PEM-NH). This version was developed and assessed using semistructured interviews, a reference group meeting, translation, adaptation, and pretesting, and psychometric assessment including exploratory and confirmatory factor analyses, and retest. We tested hypotheses to assess relations to other variables. The final factor solution comprised 41 items and 9 factors: interpersonal leadership, professional development, resources, professional leadership, input and acknowledgement, patient and next-of-kin focus, multidisciplinary collaboration, language misunderstandings, and feeling unsafe. The assessment showed that the B-PEM-NH had good psychometric properties, suggesting that the questionnaire is suitable for application in similar settings.

Nursing Home Employee and Resident Satisfaction and Resident Care Outcomes

BACKGROUND

Nursing home resident care is an ongoing topic of public discussion, and there is great interest in improving the quality of resident care. This study investigated the association between nursing home employees' job satisfaction and residents' satisfaction with care and medical outcomes.

METHODS

Employee and resident satisfaction were measured by questionnaire in 175 skilled nursing facilities in the eastern United States from 2005 to 2009. Facility-level data on residents' pressure ulcers, medically unexplained weight loss, and falls were obtained from the Centers for Medicare and Medicaid Services Long-Term Care Minimum Data Set. The association between employee satisfaction and resident satisfaction was examined with multiple and multilevel linear regression. Associations between employee satisfaction and the rates of pressure ulcers, weight loss, and falls were examined with simple and multilevel Poisson regression.

RESULTS

A 1-point increase in overall employee satisfaction was associated with an increase of 17.4 points (scale 0-100) in the satisfaction of residents and family members (p < 0.0001) and a 19% decrease in the incidence of resident falls, weight loss, and pressure ulcers combined (p < 0.0001), after adjusting for staffing ratio and percentage of resident-days paid by Medicaid.

CONCLUSION

Job satisfaction of nursing home employees is associated with lower rates of resident injuries and higher resident satisfaction with care. A supportive work environment may help increase quality of care in the nation's nursing homes.

Development of the Care Environment Scale-Long-Term Care

A critical dimension of Quality Assurance and Performance Improvement (QAPI) activity in long-term care is an analysis of the care environment, that is, the way care and services are organized. The purpose of this study was to develop and pilot test a psychometrically sound tool that long-term care staff could use to assess the care environment and guide performance improvement activity. Focus groups with 57 interdisciplinary participants in five nursing homes developed initial items, with excellent content validity (item content validity index = 1.0) evaluated by an expert panel. Pilot testing of internal consistency of the Care Environment Scale-Long-Term Care (CES-LTC) was conducted in a web-based administration of the items by 425 interdisciplinary staff members in 30 nursing homes and four assisted living facilities. The CES-LTC is internally consistent (Cronbach's alpha = .90) and accounts for approximately 71.6% of the total variance. The three factors extracted from the exploratory factor analysis are Institutional Values (k = 6), Access to Resources (k = 10), and Person-Centered Approaches (k = 12). Intrarater reliability in a subsample of 66 registered nurses revealed good test-retest results (overall intraclass correlation coefficients [ICC] = 0.78). The CES-LTC appears to be a valid and reliable measure of staff perceptions of the care environment and may be used to actively engage staff in QAPI endeavors including root cause analyses and improvement activity.

Appreciative management assessed by physiotherapists working in public or private sector: A cross-sectional study

PURPOSE

To describe how appreciative management occurs in the working environment of physiotherapists.

METHODS

Cross-sectional survey. The data was collected with an electronic questionnaire. The survey instrument was Appreciative Management Scale. The participants were 474 physiotherapists working in clinical or managerial positions from public or private sector.

RESULTS

Appreciative management was realized on an average level within physiotherapy. The highest scoring dimension was Equality and the weakest was Systematic Management. Appreciative management and all of its four categories were associated with the management education received by the manager, the respondent's position, and his or her current duties. The dimension of Appreciation of Know-how and its subdimensions of Guidance and Autonomy were recognized more often when the manager's basic training was in physiotherapy rather than another field.

CONCLUSIONS

It is important that managers in physiotherapy recognize the characteristics of appreciative management, so they can include them as part of their good practice and as part of their own leadership style. Managers in physiotherapy need to be encouraged to participate in management education and also enable the participation of others. A background in physiotherapy can be seen to further the practice and development of physiotherapy. Offering physiotherapists challenging assignments and enabling their career development in physical therapy units is therefore of great importance.

[Critical discussion on the current quality debate on long-term care-a plea for a systemic and empirical insight into the development and measurement of quality in long-term care]

Against the background of the quality debates on long-term care and recurrent reform measures in politics on this topic, a critical discussion on the current state of quality development, testing and reporting in Germany is presented. In Germany, the linear model of Donabedian's structural, process and outcome quality is still used as a basis for quality issues in nursing care; however, international research suggests that multiple and mutually interacting factors influence nursing quality and that a more systematic and systemic perspective for the further development of nursing quality (especially of features, criteria and indicators of nursing quality) appears more appropriate. This article intends to open the perspective of the development, measurement and reporting of quality in nursing and to make a critical contribution for a systemic theory development as a relevant basis for future developments of quality evaluation programs and quality reporting systems in long-term care.

Practice environment as perceived by nurses in acute care hospitals in Sharjah and North Emirates

AIM

To explore nurses' perceptions of their practice environment in acute care hospitals in Sharjah and North Emirates in the United Arab Emirates (UAE).

BACKGROUND

The health of the environment in which registered nurses' work is critical to nursing outcomes. The interest to examine the practice environment extended to the Gulf area which has a complex healthcare system including the UAE.

METHODS

The study used an exploratory descriptive design with a qualitative part using two focus group interviews. The sample size was 450 nurses selected through a random sampling method. A self-administered questionnaire including the Practice Environment Scale of Nursing Work Index (PES-NWI) was used. In addition, semi-structured interviews for two focus groups were done.

RESULTS

The results showed that UAE practicing nurses reported favorable perceptions of most aspects of their practice environment. Unfavorable perceptions were only reported for Staffing and Resource Adequacy. The analysis of focus group discussions resulted in different emerged themes such as Lack of Recognition and Career Promotion, and Nurses' Workload due to Paper and Administrative Work.

CONCLUSIONS

The findings of this study suggest that strategic interventions are needed to secure adequate staff and resources and implement an effective system for evaluation of performance.

Measuring nurses' perception of work environment: a scoping review of questionnaires

Background

Nurses’ work environment has been shown to be associated with quality of care and organizational outcomes. In order to monitor the work environment, it is useful for all stakeholders to know the questionnaires that assess or evaluate conditions for delivering nursing care. The aim of this article is: to review the literature for assessed survey questionnaires that measure nurses’ perception of their work environment, make a brief assessment, and map the content domains included in a selection of questionnaires.

Methods

The search included electronic databases of internationally published literature, international websites, and hand searches of reference lists. Eligible papers describing a questionnaire had to be; a) suitable for nurses working in direct care in general hospitals, nursing homes or home healthcare settings; and b) constructed to measure work environment characteristics that are amenable to change and related to patient and organizational outcomes; and c) presented along with an assessment of their measurement properties.

Results

The search yielded 5077 unique articles. For the final synthesis, 65 articles met inclusion criteria, consisting of 34 questionnaires measuring nursing work environments in different settings. Most of the questionnaires that we found were developed, and tested, for registered nurses in a general hospital setting. Six questionnaires were developed specifically for use in nursing home settings and one for home healthcare. The content domains covered by the questionnaires were both overlapping and unique and the terminology in use was inconsistent. The most common content domains in the work environment questionnaires were supportive managers, collaborative relationships with peers, busyness, professional practice and autonomy.

Conclusions

The findings from this review enhance the understanding of how “work environment” can be measured by an overview of existing questionnaires and domains. Our results indicate that there are very many work environment questionnaires with varying content.

Electronic supplementary material

The online version of this article (10.1186/s12912-017-0256-9) contains supplementary material, which is available to authorized users.

Factors Related to Healthcare Service Quality in Long-term Care Hospitals in South Korea: A Mixed-methods Study

Objectives

The environment of long-term care hospitals (LTCHs) is critical to the management of the quality of their services and to patient safety, as highlighted by international studies. However, there is a lack of evidence on this topic in South Korea. This study aimed to examine the factors affecting healthcare quality in LTCHs and to explore the effectiveness of their quality management.

Methods

This study used a mixed methods approach with quantitative data collected in a national survey and qualitative data from semi-structured interviews with practice-based managers. The samples included 725 nationally representative LTCHs in South Korea for the quantitative analysis and 15 administrators for the in-depth interviews.

Results

A higher installation rate of patient-safety and hygiene-related facilities and staff with longer-tenures, especially nurses, were more likely to have better healthcare quality and education for both employees and patients.

Conclusion

The need for patient-safety- and hygiene-related facilities in LTCHs that serve older adults reflects their vulnerability to certain adverse events (e.g., infections). Consistent and skillful nursing care to improve the quality of LTCHs can be achieved by developing relevant educational programs for staff and patients, thereby strengthening the relationships between them.

A Capabilities Approach to Environmental Impact on Nursing Home Resident Quality of Life

Nursing homes are the major provider of intermediate and long-term care outside of the hospital setting to individuals whose capacity for self-care is limited due to physical or cognitive impairments. Yet, despite their need for assistance, residents of nursing homes want to control their lives, set their routines, and do enjoyable things. The extent to which residents can maintain autonomy and dignity is important. The current study suggests an environmental gerontological framework, rooted in a capabilities approach, that can be used to consider environmental impact on quality of life in nursing homes. Using a cross-sectional survey of nursing home residents in Texas, environmental factors that might predict residents' quality of life as well as possible interactions of environmental factors and residents' characteristics that might predict well-being were examined. Environmental orientation and perception of social activities were important predictors of residents' quality of life, but geographic location and facility size were not important predictors. [Res Gerontol Nurs. 2017; 10(4):162-170.].

Work environment characteristics associated with quality of care in Dutch nursing homes: A cross-sectional study

BACKGROUND

A lack of relationship between direct care staffing levels and quality of care, as found in prior studies, underscores the importance of considering the quality of the work environment instead of only considering staff ratios. Only a few studies, however, have combined direct care staffing with work environment characteristics when assessing the relationship with quality of care in nursing homes.

OBJECTIVES

To examine the relationship between direct care staffing levels, work environment characteristics and perceived quality of care in Dutch nursing homes.

DESIGN

Cross-sectional, observational study in cooperation with the Dutch Prevalence Measurement of Care Problems.

SETTINGS

Twenty-four somatic and 31 psychogeriatric wards from 21 nursing homes in the Netherlands.

PARTICIPANTS

Forty-one ward managers and 274 staff members (registered nurses or certified nurse assistants) from the 55 participating wards.

METHODS

Ward rosters were discussed with managers to obtain an insight into direct care staffing levels (i.e, total direct care staff hours per resident per day). Participating staff members completed a questionnaire on work environment characteristics (i.e., ward culture, team climate, communication and coordination, role model availability, and multidisciplinary collaboration) and they rated the quality of care in their ward. Data were analyzed using multilevel linear regression analyses (random intercept). Separate analyses were conducted for somatic and psychogeriatric wards.

RESULTS

In general, staff members were satisfied with the quality of care in their wards. Staff members from psychogeriatric wards scored higher on the statement 'In the event that a family member had to be admitted to a nursing home now, I would recommend this ward'. A better team climate was related to better perceived quality of care in both ward types (p≤0.020). In somatic wards, there was a positive association between multidisciplinary collaboration and agreement by staff of ward recommendation for a family member (p=0.028). In psychogeriatric wards, a lower score on market culture (p=0.019), better communication/coordination (p=0.018) and a higher rating for multidisciplinary collaboration (p=0.003) were significantly associated with a higher grade for overall quality of care. Total direct care staffing, adhocracy culture, hierarchy culture, as well as role model availability were not significantly related to quality of care.

CONCLUSIONS

Our findings suggest that team climate may be an important factor to consider when trying to improve quality of care. Generating more evidence on which work environment characteristics actually lead to better quality of care is needed.

Is an Engaging or Soothing Environment Associated With the Psychological Well-Being of People With Dementia in Long-Term Care?

PURPOSE

To examine the relationship between environmental ambience and psychological well-being of persons with dementia.

DESIGN

A secondary analysis was conducted using observational data with repeated measures. A total of 1,857 observations from 177 persons with dementia in 17 nursing homes and 6 assisted living facilities were included.

METHODS

Psychological well-being was measured by observed displays of positive and negative emotional expressions. The environmental ambience was assessed by two subscales of the Ambiance Scale: Engaging and Soothing. Multilevel modeling was used to account for hierarchical structures in the data.

FINDINGS

An engaging environment was associated with more positive emotional expressions after controlling for covariates. However, a soothing environment was associated with neither positive nor negative emotional expressions.

CONCLUSIONS

Results suggest that the environment is an important consideration for administrators and clinicians as they respond to the mandate to actively plan and provide care to persons with dementia.

CLINICAL RELEVANCE

An environment that is relevant and interesting may promote a sense of well-being and support resident-centered care.

What interventions can improve the mental health nursing practice environment?

The nursing practice environment is an important factor for services to consider in the attraction and retention of a skilled workforce during future nursing shortages. Despite the significant number of international studies undertaken to understand the influence of the practice environment on nurse satisfaction and retention, few have been undertaken within the mental health setting. This paper reports on results from a survey conducted in a large Australian public mental health hospital to examine nurses' perceptions of their practice environment, and identifies interventions that could be implemented to improve the practice environment. The hospital is the only remaining, standalone public mental health hospital in Western Australia.

Iraqi Nurses' Perspectives on Safety Issues in Maternity Services

Background:

Studies introduce maternal and neonatal safety phenomena as important challenges to the public health, particularly in low-income countries. However, few researches are conducted on the identification of safety issues in maternity hospitals in Iraq. It was the first study on nurses’ perspectives on safety issues in Kurdistan, Iraq.

Objectives:

The current study aimed to describe nurses’ perspectives on what constitutes a safe maternity service in Kurdistan, Iraq.

Patients and Methods:

A qualitative design, based on a content analysis approach, was used. Ten Kurdish nurses who worked in the delivery room of Kurdistan, Iraq maternity hospital were recruited through purposive sampling. Semi-structured interviews were performed to collect data. All interviews were audiotaped and transcribed verbatim. Sampling continued to the level of data saturation. Data analysis was performed based on the steps suggested by Graneheim and Lundman.

Results:

Thematic analysis led to the identification of six main categories including stressful job, lack of schedule and job description, providing care with limited resources, professional unaccountability, regional sociopolitical factors, and inadequate training.

Conclusions:

Iraqi nurses identified factors such as limited health resources, lack of job description, and professional unaccountability as major safety issues in maternity services. These findings alarm the need to ensure the provision of females and neonates with appropriate care. This, however, would require coordination between Iraqi Kurdistan health authorities to provide midwifery care facilities, high-quality and relevant staff training, and an effective healthcare system in the maternity units.