Supervisory relationships in long-term care facilities: A comparative case study of two facilities using complexity science

Application of complexity theory in health and social care research: a scoping review

BACKGROUND

Complexity theory has been chosen by many authors as a suitable lens through which to examine health and social care. Despite its potential value, many empirical investigations apply the theory in a tokenistic manner without engaging with its underlying concepts and underpinnings.

OBJECTIVES

The aim of this scoping review is to synthesise the literature on empirical studies that have centred on the application of complexity theory to understand health and social care provision.

METHODS

This scoping review considered primary research using complexity theory-informed approaches, published in English between 2012 and 2021. Cochrane Database of Systematic Reviews, MEDLINE, CINAHL, EMBASE, Web of Science, PSYCHINFO, the NHS Economic Evaluation Database, and the Health Economic Evaluations Database were searched. In addition, a manual search of the reference lists of relevant articles was conducted. Data extraction was conducted using Covidence software and a data extraction form was created to produce a descriptive summary of the results, addressing the objectives and research question. The review used the revised Arksey and O'Malley framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR).

RESULTS

2021 studies were initially identified with a total of 61 articles included for extraction. Complexity theory in health and social care research is poorly defined and described and was most commonly applied as a theoretical and analytical framework. The full breadth of the health and social care continuum was not represented in the identified articles, with the majority being healthcare focused.

DISCUSSION

Complexity theory is being increasingly embraced in health and care research. The heterogeneity of the literature regarding the application of complexity theory made synthesis challenging. However, this scoping review has synthesised the most recent evidence and contributes to translational systems research by providing guidance for future studies.

CONCLUSION

The study of complex health and care systems necessitates methods of interpreting dynamic prcesses which requires qualitative and longitudinal studies with abductive reasoning. The authors provide guidance on conducting complexity-informed primary research that seeks to promote rigor and transparency in the area.

REGISTRATION

The scoping review protocol was registered at Open Science Framework, and the review protocol was published at BMJ Open (https://bit.ly/3Ex1Inu).

Organizational Factors Associated with Certified Nursing Assistants' Job Satisfaction during COVID-19

Given the instability of the nursing home (NH) certified nursing assistant (CNA) workforce and the challenging demands during COVID-19, it is important to understand the organizational factors that are correlated with job satisfaction which is a major predictor of CNA turnover. The purpose of this study was to determine the associations between quality of supervisor relationships, organizational supports, COVID-19 work-related stressors, and job satisfaction among CNAs in NHs. The results indicate that CNAs who reported a more optimal relationship with their supervisors, felt appreciated for the job they do and worked in NHs with lower COVID-19 resident infection rates tended to report higher rates of job satisfaction. The COVID-19 work-related stressors of increased workload demands and understaffing were associated with lower rates of job satisfaction. The study has practical implications for employers regarding how to support CNAs to improve job satisfaction especially during a crisis.

The Required Competencies of Bachelor- and Master-Educated Nurses in Facilitating the Development of an Effective Workplace Culture in Nursing Homes: An Integrative Review

BACKGROUND

Nursing home care is undergoing significant changes. This requires innovative teams operating in an effective workplace culture characterized by person-centeredness and offering evidence-based care. A pivotal role for bachelor- and master-educated nurses (BNs/MNs) is foreseen to facilitate such cultures; however, there is currently no comprehensive overview of what competencies this requires.

OBJECTIVES

To identify what competencies are required from BNs/MNs in facilitating the development of an effective workplace culture in nursing homes.

METHODS AND DESIGN

We conducted an integrative review (IR) using Whittemore and Knafl's method. We searched the PubMed, CINAHL, and PsycINFO databases for studies published between January 2010 and December 2021 in English. Two independent reviewers determined whether studies met inclusion: bachelor- or master-educated nurse; nursing home; professional competencies; and mixed methods or qualitative and qualitative studies. We applied the CASP appraisal tool and analyzed the data by applying content analysis.

RESULTS

Sixteen articles were included. Five themes were identified representing required competencies for BNs/MNs facilitating: (1) learning cultures in nursing practice; (2) effective work relationships within teams; (3) leadership capability within teams; (4) implementation of guidelines, standards, and protocols; (5) a work environment acknowledging grief and loss of residents within teams.

CONCLUSIONS

It shows that the BN/MN applies five competencies associated with a facilitator role to promote the development of an effective workplace culture to achieve a safe, high-level quality of care, satisfaction, and well-being. An overarching leadership as a change champion will support teams to achieve a quality that should guide the transformation in nursing care.

Level of nurse supportive supervision and its influencing factors in long-term care facilities

Quality of care provided by personal support workers (PSWs) in long-term care facilities (LTCFs) is associated with the supportive supervisory performance of registered nurses (RNs). To determine the level of supportive supervision of RNs and its influencing factors in LTCFs in East China, a cross-sectional survey was conducted in 12 LTCFs using self-designed sociodemographic questionnaires and the Chinese version of the Supportive Supervisory Scale. A total of 643 PSWs supervised by 260 RNs were surveyed. The average supportive supervision score was 59.60 ± 7.53, representing a moderate level of supervisory support. Supportive supervision was found to be positively correlated with the PSW's years of working, the RN's education, position, number of years in nursing, having access to managerial training as well as the RN/PSW ratio in the unit (p < 0.05). These factors can be modified to potentially influence the supportive capacity of nurse supervisors in LTCFs.

Characteristics of nursing home units with high versus low levels of person-centred care in relation to leadership, staff- resident- and facility factors: findings from SWENIS, a cross-sectional study in Sweden

BACKGROUND

The context of care consists of factors that determines the extent to which staff can offer person-centred care. However, few studies have investigated factors that can explain variation in levels of person-centred care among nursing home units. The aim of this study was to explore factors characterizing nursing home units with high and low degree of person-centred care, with focus on leadership, staff, resident and facility factors.

METHODS

Cross-sectional data from residents, staff, and managers in 172 randomly selected nursing homes in Sweden were collected in 2014. Activities of Daily Living Index, Gottfries' cognitive scale, Person-centred Care Assessment Tool together with demographic information and estimations of leadership engagement was used. Independent samples t-test and Chi2 test were conducted.

RESULTS

Highly person-centred units were characterised by leaders engaging in staff knowledge, professional development, team support and care quality. In highly person-centred units' staff also received supervision of a nurse to a larger extent. Highly person-centred units were also characterised as dementia specific units, units with fewer beds and with a larger proportion of enrolled nurses. No differences in degree of person-centred care were seen between public or private providers.

CONCLUSIONS

This study provides guidance for practitioners when designing, developing and adapting person-centred units in aged care contexts. Managers and leaders have an important role to promote the movement towards a person-centred practice of care, by supporting their staff in daily care, and engaging in staff knowledge and professional development. Targeting and adjusting environmental factors, such as provide small and dementia adapted environments to match the residents' personal preferences and capacity are also important when striving towards person-centredness.

To whom health care aides report: Effect on nursing home resident outcomes

INTRODUCTION

Health care aides (personal support workers and nursing assistants) provide ~80%-90% of direct care to residents in nursing homes; it is therefore important to understand whether supervision of health care aides affects quality of care. We sought to determine whether health care aide reporting practices are associated with resident outcomes in nursing homes.

DESIGN AND METHODS

We conducted a cross-sectional secondary analysis of survey data of 3991 health care aides from 322 units in 89 nursing homes in Western Canada. We then linked resident data from the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 database to care aide surveys at the unit level. We used hierarchical mixed models to determine if the proportion of health care aides reporting to a respective nursing leader role was associated with 13 practice sensitive quality indicators of resident care.

RESULTS

Most health care aides reported to a registered nurse (RN, 44.5%) or licenced practical nurse (LPN, 53.3%). Only 2.2% of health care aides reported to a care manager and were excluded from the analysis. Resident outcomes for only declining behavioural symptoms were more favourable when a higher proportion of health care aides (on a unit) reported to RNs, β = -0.004 (95% CI -0.006, -0.001, p = .004). The remaining indicators were not affected by care aide reporting practices.

DISCUSSION AND IMPLICATIONS

Resident outcomes as evaluated by the indicators appear largely unaffected by care aide reporting practices. LPNs' increasing scope of practice and changing work roles and responsibilities in nursing homes across Western Canada may explain the findings.

Cross-cultural validation and psychometric testing of the supportive supervisory scale in Spanish

BACKGROUND

Supervisory effectiveness in long-term care facilities has been identified a key factor in staff satisfaction and quality of care. Determining its utility in Spanish speaking countries will assist with understanding different cultural and health service contexts.

OBJECTIVES

To develop and psychometrically test the Supervisory Support Scale in Spanish. The Spanish version of the Supportive Supervisory Scale could be useful for cross-cultural comparisons of supervisory support, which is a key factor to improving work relationships in long-term care facilities.

METHODS

Validation was carried out with 405 participants in 37 long-term care facilities. One-way analysis of variance was the test of significance performed to examine the differences among the facilities and Pearson product-moment correlations were used to assess construct validation of the scale. The mean and standard deviation were calculated for each supervisory score in each facility. Structural equation modelling was used to confirm the dimensions of the scale.

RESULTS

The item-to-item correlations were positive, ranging from 0.44 to 0.78, indicating good reliability of the scale. The coefficient alpha for the total scale was 0.96. The 15-item had mean item scores which ranged from 2.89 to 3.96 (SD = 1.01-1.26). Standardised factor loadings ranged within a narrow range: 0.75-0.86 for the 'respecting uniqueness' latent variable and 0.76-0.88 for the 'being reliable' latent variable. Construct validity was demonstrated as measure was positively associated with job satisfaction (r = 0.412, p < 0.0001) and was negatively correlated with HCAs' stress and burden.

CONCLUSION

The two-factor solution identified in the original scale that highlighted two key attributes of the supervisor; being reliable and respecting uniqueness, was also demonstrated in the Spanish Supervisory Support Scale as there was a moderate fit of the model.

IMPLICATIONS FOR PRACTICE

The Spanish version of the Supportive Supervisory Scale could be useful for cross-cultural comparisons of supervisory support in nursing facilities which is a key factor to improving staff relationships and care in nursing facilities.

The supportive supervisory scale: psychometric properties in Chinese health care aides samples

Objective

To sinicize the Supportive Supervisory Scale (SSS) and analyze the psychometric properties of the Chinese version of SSS (SSS-C).

Methods

The SSS (the original English version) was firstly sinicized and adjusted, then its psychometric properties were examined in 300 health care aides from four long-term care (LTC) facilities. SPSS 22.0 was used to process the data and calculate the reliability and validity.

Results

The 15-item SSS-C had satisfactory internal consistency (Cronbach’s α coefficient = 0.852), split half reliability (Spearman-Brown coefficient = 0.834) and test–retest reliability (Pearson correlation coefficient = 0.784), and three factors were extracted. If the four items with their communality < 0.4 were deleted, the remaining 11 items could explain 55.654% of the total variance. The discriminant validity of the SSS-C varied significantly between sites.

Conclusions

The Chinese version of SSS can be used to effectively measure the supervisory support of the nurses within the LTC settings.

Factors Influencing Nurse Assistants' Job Satisfaction in Nursing Homes in Canada and Spain: A Comparison of Two Cross-Sectional Observational Studies

OBJECTIVES

To access associations between job satisfaction and supervisory support as moderated by stress.

METHODS

For this cross-sectional study, data collected from 591 nursing assistants in 42 nursing homes in Canada and Spain were analyzed with mixed-effects regression.

RESULTS

In both countries, stress related to residents' behaviors was negatively associated with job satisfaction, and, in Canada, it moderated the positive association between supervisory support and job satisfaction. Stress related to family conflict issues moderated the positive association of supervisory support and job satisfaction differently in each location: in Canada, greater stress was associated with a weaker association between supervisory support and job satisfaction; in Spain, this was also observed but only when supervisory support was sufficiently weak.

DISCUSSION

Stress was associated with lower job satisfaction and moderated the association of supervisory support and job satisfaction, reinforcing the importance of supervisors supporting nursing assistants, especially during the COVID-19 pandemic.

The influence of supervisory support, work effectiveness, work empowerment and stress secondary to residents' responsive behaviours on job satisfaction of nursing staff: A multisite cross-sectional study

AIM

To examine the association between stress secondary to residents' responsive behaviours and job satisfaction of nurses and nursing assistants working in nursing homes. To test whether supervisory support, work effectiveness and work empowerment confound this relationship.

BACKGROUND

Understanding how the stress secondary to residents' responsive behaviours influences job satisfaction for staff and determining the factors influencing this relationship are important for retention of staff in nursing homes. The term 'responsive behaviours' refers to the subset of behavioural and psychological symptoms of dementia.

METHODS

Survey responses from 191 nursing assistants and 81 nurses in five nursing homes in Ontario were analysed.

RESULTS

Staff's stress attributed to residents' responsive behaviours was negatively associated with job satisfaction. This direct effect was weakened by more than a third through the confounding net effects of supervisory support, work effectiveness and work empowerment.

CONCLUSION

The work environment created by leaders in nursing homes can lessen the influence of stress secondary to residents' responsive behaviours on staffs' job satisfaction.

IMPLICATIONS FOR NURSING MANAGEMENT

Supervisors need training and education to support and mentor their staff effectively, and to guide their use of evidence-based practices that integrate the patient-centred care approach in order to effectively respond and minimize responsive behaviours.

A scoping review of complexity science in nursing

AIM

To describe how complexity science has been integrated into nursing.

DESIGN

A scoping review.

DATA SOURCE/REVIEW METHOD

Academic Search Elite, Scopus, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, PubMed and Web of Science were searched November 2016, updated in October 2017 and January 2020. The working process included: problem identification, literature search, data evaluation, synthesizing and presentation.

RESULTS

Four categories were found in the included 89 articles: (a) how complexity science is integrated into the nursing literature in relation to nursing education and teaching; (b) patients' symptoms, illness outcome and safety as characteristics of complexity science in nursing; (c) that leaders and managers should see organizations as complex and adaptive systems, rather than as linear machines; and (d) the need for a novel approach to studying complex phenomena such as healthcare organizations. Lastly, the literature explains how complexity science has been incorporated into the discourse in nursing and its development.

CONCLUSION

The review provided strong support for use in complexity science in the contemporary nursing literature. Complexity science is also highly applicable and relevant to clinical nursing practice and nursing management from an organizational perspective. The application of complexity science as a tool in the analysis of complex nursing systems could improve our understanding of effective interactions among patients, families, physicians and hospital and skilled nursing facility staff as well as of education.

IMPACT

Understanding complexity science in relation to the key role of nurses in the healthcare environment can improve nursing work and nursing theory development. The use of complexity science provides nurses with a language that liberates them from the reductionist view on nursing education, practice and management.

Exploring a Common Data Element for International Research in Long-Term Care Homes: A Measure for Evaluating Nursing Supervisor Effectiveness

The aim of this study is to recommend a common data element (CDE) to measure supervisory effectiveness of staff working in LTC homes that can be used in international research. Supervisory effectiveness can serve as a CDE in an effort to establish an international, person-centered LTC research infrastructure in accordance with the aims of the WE-THRIVE group (Worldwide Elements to Harmonize Research in Long Term Care Living Environments). A literature review was completed and then a panel of experts independently reviewed and prioritized appropriateness of the measures with mindfulness of their potential applications to international LTC settings. The selection of a recommended CDE measure was guided by the WE-THRIVE group's focus on capacity rather than deficits, the expected availability of internationally comparable data and the goal to provide a short, ecologically viable measurement, specifically for low- and middle-income countries. Two measures were considered as the CDE for supervisory effectiveness, Benjamin Rose Relationship Scale and the Supervisory Support Scale; however, given that the latter measure has been translated in Spanish and Chinese and has been tested with nursing assistants in both of these countries with good psychometric properties, our group recommends it as the CDE going forward.