Extending work environment research into home health settings

Developing the nursing practice environment scale for home health care: A trial study in Japan

AIM

To develop the nursing practice environment scale in home health care (NPES-HHC), which measures the attractiveness of nursing practice environments in Japan.

DESIGN

Cross-sectional study.

METHODS

The answers of 1,050 mail surveys conducted for nurses at 421 home-visit nursing agencies in Japan were analysed. Exploratory and confirmatory factor analyses of the NPES-HHC's candidate items were performed. Relationships between the newly developed NPES-HHC and participants' intention to remain at the workplace, job satisfaction and quality of care were also tested.

RESULTS

A seven-dimensional model with 37 items was obtained by exploratory factor analysis (Cronbach's alpha: 0.77-0.92). Confirmatory factor analysis supported this model. NPES-HHC scores had significant positive relations with participants' intention to remain at the workplace, job satisfaction and quality of care (p < .01). The NPES-HHC is a reliable and valid instrument to assess the attractiveness of the practice environment for home-visit nursing agencies.

Organisational support and turnover intentions: A moderated mediation approach

Aim

The current study aims to examine the moderating role of psychological ownership in the process that translates organisational support into nurses’ turnover intentions through job satisfaction.

Design

A cross‐sectional research design was used to test the hypotheses.

Method

Using a purposive sampling 341 self‐completed survey data were collected from nurses working in two public hospitals in Iran. Structural equation modelling was used to analyse the data.

Result

The research revealed that organisational support and job satisfaction were negatively related to a healthcare professionals’ turnover intention. Moreover, job satisfaction mediated the negative relationship between organisational support and turnover intention. The research also revealed that psychological ownership strengthened the positive relationship between organisational support and job satisfaction.

Factors associated with homecare coordination and quality of care: a research protocol for a national multi-center cross-sectional study

INTRODUCTION

The persistent fragmentation of home healthcare reflects inadequate coordination between care providers. Still, while factors at the system (e.g., regulations) and organisational (e.g., work environment) levels crucially influence homecare organisation, coordination and ultimately quality, knowledge of these factors and their relationships in homecare settings remains limited.

OBJECTIVES

This study has three aims: [1] to explore how system-level regulations lead to disparities between homecare agencies' structures, processes and work environments; [2] to explore how system- and organisation-level factors affect agency-level homecare coordination; and [3] to explore how agency-level care coordination is related to patient-level quality of care.

DESIGN AND METHODS

This study focuses on a national multi-center cross-sectional survey in Swiss homecare settings. It will target 100 homecare agencies, their employees and clients for recruitment, with data collection period planned from January to June 2021. We will assess regulations and financing mechanisms (via public records), agency characteristics (via agency questionnaire data) and homecare employees' working environments and coordination activities, as well as staff- and patient-level perceptions of coordination and quality of care (via questionnaires for homecare employees, clients and informal caregivers). All collected data will be subjected to descriptive and multi-level analyses.

DISCUSSION

The first results are expected by December 2021. Knowledge of factors linked to quality of care is essential to plan and implement quality improvement strategies. This study will help to identify modifiable factors at multiple health system levels that might serve as access points to improve coordination and quality of care.

Development of a short questionnaire based on the Practice Environment Scale-Nursing Work Index in primary health care

Background

Professional nursing environments determine the quality of care and patient outcomes. Assessing the quality of environments is essential to improve and obtain better health outcomes. Simplifying and shortening the way to evaluate environments reliably is also important to help nurses better understand the strengths and weaknesses of their environments. In that sense, identifying essential elements of nursing environments would allow the construction of short assessment tools to improve such environments.

Objective

To construct a short tool to assess primary health care (PHC) nursing environments based on the Practice Environment Scale-Nursing Work Index (PES-NWI) questionnaire.

Methods

Observational, cross-sectional, analytical study (data collection February-April 2015). Tool: PES-NWI (31 items). Population: PHC nurses (three health districts in Valencia, Spain) with more than 3 months in the organization. The nurses were asked to select the 10 elements of the questionnaire (items) that they considered key to facilitate and improve professional care, establishing as a final selection criterion that they obtain a global election >40%. Variables: sociodemographic and 31 questionnaire items. Analysis: descriptive statistics, reliability, multidimensional scaling (ALSCAL), factor analysis, multiple linear regression. Finally, we have analyzed the concordance between both measurements (TOP10 score on the full scale score) using the Bland-Altman method.

Results

Study sample = 269 (Response rate = 80.29%). A total of 10 elements were identified based on selection frequency of the questionnaire PES-NWI. A factorial analysis explained 62.1% of variance, internal structure of three dimensions: (1) Participation in leadership and management, (2) Nursing foundations for quality of care, (3) Adequacy of resources, with Accumulate Variance explained: Component (1): 24%; Component (2): 43.1%; Component (3): 62.1%. Reliability (Cronbach's Alpha) was 0.816 for short questionnaire, and >0.8 for all measurements. Stress = 0.184 and RSQ = 0.793. Bland-Altman method: the scaling tends to be 1.92 points higher (equivalent to a maximum deviation of 1.54%) than the full-scale PES-NWI score (max score on PES-NWI = 124 points).

Conclusions

It is possible to identify essential elements of environments to construct a short tool that simplifies the study of PHC environments. Conducting rapid studies of environments will provide managers with information about specific elements that require prioritization to enhance quality of care and safety.

How home health nurses plan their work schedules: A qualitative descriptive study

AIMS AND OBJECTIVES

To describe how home health nurses plan their daily work schedules and what challenges they face during the planning process.

BACKGROUND

Home health nurses are viewed as independent providers and value the nature of their work because of the flexibility and autonomy they hold in developing their work schedules. However, there is limited empirical evidence about how home health nurses plan their work schedules, including the factors they consider during the process and the challenges they face within the dynamic home health setting.

DESIGN

Qualitative descriptive design.

METHODS

Semi-structured interviews were conducted with 20 registered nurses who had >2 years of experience in home health and were employed by one of the three participating home health agencies in the mid-Atlantic region of the United States. Data were analysed using conventional content analysis.

RESULTS

Four themes emerged about planning work schedules and daily itineraries: identifying patient needs to prioritise visits accordingly, partnering with patients to accommodate their preferences, coordinating visit timing with other providers to avoid overwhelming patients, and working within agency standards to meet productivity requirements. Scheduling challenges included readjusting the schedule based on patient needs and staffing availability, anticipating longer visits, and maintaining continuity of care with patients.

CONCLUSION

Home health nurses make autonomous decisions regarding their work schedules while considering specific patient and agency factors, and overcome challenges related to the unpredictable nature of providing care in a home health setting. Future research is needed to further explore nurse productivity in home health and improve home health work environments.

RELEVANCE TO CLINICAL PRACTICE

Home health nurses plan their work schedules to provide high quality care that is patient-centered and timely. The findings also highlight organisational priorities to facilitate continuity of care and support nurses while alleviating the burnout associated with high productivity requirements.

Home health nurse decision-making regarding visit intensity planning for newly admitted patients: a qualitative descriptive study

Despite patients referred to home health having diverse and complex needs, it is unknown how nurses develop personalized visit plans. In this qualitative descriptive study, we interviewed 26 nurses from three agencies about their decision-making process to determine visit intensity and analyzed data using directed content analysis. Following a multifactorial assessment of the patient, nurses relied on their experience and their agency's protocols to develop the personalized visit plan. They revised the plan based on changes in the patient's clinical condition, engagement, and caregiver availability. Findings suggest strategies to improve visit planning and positively influence outcomes of home health patients.

Pathway to better patient care and nurse workforce outcomes in home care

BACKGROUND

Unlike the Magnet Recognition Program, the newer Pathway to Excellence Program designed to improve work environments in a broader range of organizations has not yet been the focus of substantial research.

PURPOSE

The purpose of the study was to examine the association of Pathway to Excellence Program Standards with better patient care quality and workforce outcomes in home care.

METHOD

Cross-sectional survey of registered nurses yielded informants from 871 home care agencies in the United States. Variables representing each of the 12 Pathway Standards were entered into logistic regression models to determine associations with better patient care and nurse workforce outcomes.

DISCUSSION

All Pathway Standards are strongly and significantly associated with better patient care and better workforce outcomes. Home care agencies with better-rated professional work environments consistently had better patient care and nurse workforce outcomes.

CONCLUSIONS

This study validates the Pathway to Excellence Standards as important to patient care quality and nursing workforce outcomes in home care.

Job demands-resources predicting burnout and work engagement among Belgian home health care nurses: A cross-sectional study

BACKGROUND

A better knowledge of the job aspects that may predict home health care nurses' burnout and work engagement is important in view of stress prevention and health promotion. The Job Demands-Resources model predicts that job demands and resources relate to burnout and work engagement but has not previously been tested in the specific context of home health care nursing.

PURPOSE

The present study offers a comprehensive test of the Job-Demands Resources model in home health care nursing. We investigate the main and interaction effects of distinctive job demands (workload, emotional demands and aggression) and resources (autonomy, social support and learning opportunities) on burnout and work engagement.

METHODS

Analyses were conducted using cross-sectional data from 675 Belgian home health care nurses, who participated in a voluntary and anonymous survey.

RESULTS

The results show that workload and emotional demands were positively associated with burnout, whereas aggression was unrelated to burnout. All job resources were associated with higher levels of work engagement and lower levels of burnout. In addition, social support buffered the positive relationship between workload and burnout.

CONCLUSIONS

Home health care organizations should invest in dealing with workload and emotional demands and stimulating the job resources under study to reduce the risk of burnout and increase their nurses' work engagement.

Indicators of Job Satisfaction of Home Healthcare Nurses in the San Francisco Bay Area of California

The purpose of this study was to identify the factors that provide job satisfaction for home healthcare nurses and to determine if the nurses' educational level makes a difference in job satisfaction. Data were collected using Ellenbecker's (2004) 21-item Home Healthcare Nurses Job Satisfaction Scale. The study results indicated the majority of this population of home healthcare nurses was satisfied on all items, except in having the power to change agency policy. Educational level made no significant difference in job satisfaction. Recommendations include encouraging agencies to include clinicians in policy decision-making and management of patient care. Nursing education programs should ensure nurses graduate with the skills necessary for policy development and to make decisions that positively impact patient care.

Development and testing of the Dementia Symptom Management at Home (DSM-H) program: An interprofessional home health care intervention to improve the quality of life for persons with dementia and their caregivers

Home health care agencies are increasingly taking care of sicker, older patients with greater comorbidities. However, they are unequipped to appropriately manage these older adults, particular persons living with dementia (PLWD). We therefore developed the Dementia Symptom Management at Home (DSM-H) Program, a bundled interprofessional intervention, to improve the care confidence of providers, and quality of care delivered to PLWD and their caregivers. We implemented the DSM-H with 83 registered nurses, physical therapists, and occupational therapists. Overall, there was significant improvement in pain knowledge (5.9%) and confidence (26.5%), depression knowledge (14.8%) and confidence (36.1%), and neuropsychiatric symptom general knowledge (16.8%), intervention knowledge (20.9%), attitudes (3.4%) and confidence (27.1%) at a statistical significance of (P < .0001). We also found significant differences between disciplines. Overall, this disseminable program proved to be implementable and improve clinician's knowledge and confidence in caring for PLWD, with the potential to improve quality of care and quality of life, and decrease costs.

Changes in Payment Regulation and Acute Care Use for Total Hip Replacement: Trends in Length of Stay, Costs, and Discharge, 1997-2012

PURPOSE

To describe trends in the length of stay (LOS), costs, mortality, and discharge destination among a national sample of total hip replacement (THR) patients between 1997 and 2012.

DESIGN

Longitudinal retrospective design

METHODS

Descriptive analysis of the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample data.

FINDINGS

A total of 3,516,636 procedures were performed over the study period. Most THR patients were women, and the proportion aged 44-65 years increased. LOS decreased from 5 to 3 days. Charges more than doubled, from $22,184 to $53,901. Deaths decreased from 43 to 12 deaths per 10,000 patients. THR patients discharged to an institutional setting declined, while those discharged to the community increased.

CONCLUSION

We found an increase in THR patients, who were younger, women, had private insurance, and among those discharged to community-based settings.

CLINICAL RELEVANCE

Findings have implications for patient profiles, workplace environments, quality improvement, and educational preparation of nurses in acute and postacute settings.

Home health agency work environments and hospitalizations

BACKGROUND

An important goal of home health care is to assist patients to remain in community living arrangements. Yet home care often fails to prevent hospitalizations and to facilitate discharges to community living, thus putting patients at risk of additional health challenges and increasing care costs.

OBJECTIVES

To determine the relationship between home health agency work environments and agency-level rates of acute hospitalization and discharges to community living.

METHODS AND DESIGN

Analysis of linked Center for Medicare and Medicaid Services Home Health Compare data and nurse survey data from 118 home health agencies. Robust regression models were used to estimate the effect of work environment ratings on between-agency variation in rates of acute hospitalization and community discharge.

RESULTS

Home health agencies with good work environments had lower rates of acute hospitalizations and higher rates of patient discharges to community living arrangements compared with home health agencies with poor work environments.

CONCLUSION

Improved work environments in home health agencies hold promise for optimizing patient outcomes and reducing use of expensive hospital and institutional care.

Home care nurses' experience of job stress and considerations for the work environment

Home care nurses report increased stress in their jobs due to work environment characteristics that impact professional practice. Stressors and characteristics of the professional practice environment that moderate nurses' experience of job stress were examined in this embedded multiple case study. Real life experiences within a complex environment were drawn from interviews and observations with 29 participants across two home care agencies from one eastern U.S. state. Findings suggest that role overload, role conflict, and lack of control can be moderated in agencies where there are meaningful opportunities for shared decision making and the nurse-patient relationship is supported.

Nursing practice environment and registered nurses' job satisfaction in nursing homes

PURPOSE

 Recruiting and retaining registered nurses (RNs) in nursing homes is problematic, and little research is available to guide efforts to make nursing homes a more attractive practice environment for RNs. The purpose of this study was to examine relationships between aspects of the nursing practice environment and job satisfaction among RNs in nursing homes. 

DESIGN AND METHODS

 The sample included 863 RNs working as staff RNs in 282 skilled nursing facilities in New Jersey. Two-level hierarchical linear modeling was used to account for the RNs nested by nursing homes. 

RESULTS

 Controlling for individual and nursing home characteristics, staff RNs' participation in facility affairs, supportive manager, and resource adequacy were positively associated with RNs' job satisfaction. Ownership status was significantly related to job satisfaction; RNs working in for-profit nursing homes were less satisfied. 

IMPLICATIONS

 A supportive practice environment is significantly associated with higher job satisfaction among RNs working in nursing homes. Unlike other nursing home characteristics, specific dimensions of the nursing practice environment can be modified through administrative actions to enhance RN job satisfaction.

Nurses' practice environments, error interception practices, and inpatient medication errors

PURPOSE

Medication errors remain a threat to patient safety. Therefore, the purpose of this study was to determine the relationships among characteristics of the nursing practice environment, nurse staffing levels, nurses' error interception practices, and rates of nonintercepted medication errors in acute care hospitals.

DESIGN

This study, using a nonexperimental design, was conducted in a sample of 82 medical-surgical units recruited from 14 U.S. acute care hospitals. Registered nurses (RNs) on the 82 units were surveyed, producing a sample of 686 staff nurses.

METHODS

Data collected for the 8-month study period included the number of medication errors per 1,000 patient days and the number of RN hours per patient day. Nurse survey data included the Practice Environment Scale of the Nursing Work Index as a measure of environmental characteristics; a metric of nurses' interception practices was developed for the study. All survey measures were aggregated to the unit level prior to analysis with hierarchical linear modeling.

FINDINGS

A supportive practice environment was positively associated with error interception practices among nurses in the sample of medical-surgical units. Importantly, nurses' interception practices were inversely associated with medication error rates.

CONCLUSIONS

A supportive practice environment enhances nurses' error interception practices. These interception practices play a role in reducing medication errors.

CLINICAL RELEVANCE

When supported by their practice environments, nurses employ practices that can assist in interrupting medication errors before they reach the patients.

Work environment characteristics of high-quality home health agencies

This concurrent mixed-method study examines the nurse work environment of high-quality Medicare-certified home health agencies. High-quality (n=6) and low-quality (n=6) home health agencies were recruited using agency-level publicly reported patient outcomes. Direct care registered nurses (RNs) from each agency participated in a focus group and completed the Practice Environment Scale of the Nurse Work Index (PES-NWI). No significant differences were found in the PES-NWI results between nurses working in high- and low-quality agencies, though nurses in high-quality agencies scored higher on all subscales. Nurses working in all the high-quality agencies identified themes of adequate staffing, supportive managers, and team work. These themes were not consistently identified in low-quality agencies. Themes of supportive managers and team work are reflective of effective leadership at the manager level. Agencies struggling to improve quality of care might consider developing their managers' leadership skills.

Organizational traits, care processes, and burnout among chronic hemodialysis nurses

In light of evidence linking registered nurse (RN) staffing levels to patient outcomes in chronic hemodialysis facilities, U.S. government regulations have set minimum RN staffing requirements during dialysis. Consequently, facility administrators are focused on decreasing nurse attrition in this crucial practice setting. This study used a cross-sectional, correlational design to investigate the effects of workload, practice environment, and care processes on burnout among nurses in U.S. chronic hemodialysis centers and to determine the association between burnout and nurses' intentions to leave their jobs. Findings indicate that predictors were associated with an increased likelihood of nurse burnout and that nurses experiencing burnout were more likely to be planning to leave their jobs. Findings have important implications for retention of nurses, enhancement of patient safety, and adherence to new federal staffing requirements in chronic hemodialysis units.

Home healthcare practice environment: predictors of RN satisfaction

Since 2000, Medicare-certified home healthcare agencies have undergone significant regulatory changes that directly affect registered nurses. The satisfaction of 201 nurses from 19 home healthcare agencies was examined. Home healthcare nurses reported slightly lower satisfaction than hospital nurses and were approximately 50% less satisfied than they were in 2000. Satisfaction had a negative relationship with years worked as a home healthcare nurse (r= -.25, p< .01). Controlling for years of home healthcare experience, control over practice decisions and practice setting decisions were significant predictors of satisfaction. With the demand for home healthcare nurses expected to increase 109% by 2020, development of a National Database of Nursing Quality Indicators for home healthcare that includes satisfaction as a nurse-sensitive outcome might be helpful.