Dementia, nurse staffing, and health outcomes in nursing homes

OBJECTIVE

To estimate and contrast the relationships between nurse staffing and health outcomes in nursing homes with low and high dementia census, to understand the association of staffing hours with dementia care quality.

DATA SOURCES AND STUDY SETTING

A national sample of nursing homes during 2017-2019 (pre-COVID). Data included the Payroll-Based Journal, Medicare Claims, Nursing Home Care Compare, and Long-Term Care Focus.

STUDY DESIGN

Retrospective, regression analyses. We estimated separate linear models predicting six long-term facility-level outcomes. Independent variables included staffing hours per resident-day (HPRD) interacted with the facility percentage of dementia residents, controlling for other resident and facility characteristics.

DATA COLLECTION/EXTRACTION METHODS

Hospital-based nursing homes, those with fewer than 30% dementia residents, and missing data were excluded.

PRINCIPAL FINDINGS

We found that registered nurses and certified nurse assistants HPRDs were likely to exhibit positive returns in terms of outcomes throughout most of the range of HPRD for both high and low-census dementia facilities, although, high- and low-dementia facilities differed in most outcome rates at all staffing levels. Average predicted antipsychotics and activities of daily living as functions of HPRD were worse in higher dementia facilities, independent movement, and hospitalizations did not differ significantly, and Emergency Rooms and pressure sores were worse in lower dementia facilities. Average marginal effects were not statistically different [CI included zero] between the high and low dementia facilities for any outcome.

CONCLUSIONS

These findings suggest that increasing staffing will improve outcomes by similar increments in both low- and high-dementia facilities for all outcomes. However, at any given level of staffing, absolute differences in outcomes between low- and high-dementia facilities remain, suggesting that additional staffing alone will not suffice to close these gaps. Further studies are required to identify opportunities for improvement in performance for both low- and high-dementia census facilities.

Factors Influencing Hospitalization of Nursing Home Residents in Korea Using Regularized Negative Binomial Regression

The appropriateness of hospitalization for nursing home (NH) residents is still up for debate, with determining factors including timeliness, available treatment, healthcare staff, medication options in hospitals, and safety issues. Although the factors leading to hospitalization have been studied expansively, research on staffing is limited. Thus, this study aimed to investigate organizational predictors, nurse staffing, and government incentives and find important factors to hospitalization due to infection or disease among NH residents in Korea. A cross-sectional design was used, and data were collected via survey from a total of 51 NHs from August 27, 2021 to March 25, 2022. A total of 32 explanatory variables were included. The response variable was the count of hospitalized residents due to infection or disease. We analyzed data using least absolute shrinkage and negative binomial regression. We found that registered nurses' increased hours per resident day were related to decreased hospitalizations due to infection or disease. Appropriate retention and recruitment of nurse staffing with professional leadership should be performed to increase the quality of care for NH residents.

Do nursing homes with a higher proportion of residents with dementia have greater or fewer complaints?

Objectives: Nursing home (NH) residents' capacity to communicate deteriorates with dementia. Consequently, NHs with high proportions of people living with dementia (PLWD) may receive fewer resident complaints, and/or investigating complaints may be challenging. We assessed NHs' proportion of PLWD in relation to total and substantiated complaints. Methods: Data were from the ASPEN Complaints/Incident Tracking System and the Certification and Survey Provider Enhanced Reports (2017). NHs (N = 15,499) were categorized based on high (top-10%), medium (middle-80%), and low (bottom-10%) dementia prevalence. Negative binomial Poisson regression assessed complaint patterns in relation to NHs' high/low (vs. medium) proportions of PLWD and other facility/resident characteristics. Results: Compared to NHs with medium-dementia prevalence, NHs with low proportions of PLWD had higher total (average marginal effect [AME] = 0.16, p < 0.001) and substantiated (AME = 0.30, p < 0.001) complaints, whereas NHs with high proportions of PLWD had fewer total (AME= -0.07; p < 0.05) and substantiated (AME= -0.11, p < 0.05) complaints. Also, NHs' profit status, chain-affiliation, size, staffing, and resident ethnicity were associated with total and substantiated complaints. Conclusion: The association between high proportions of PLWD and lower NH complaints suggests either that these NHs have higher overall quality or that complaints are underreported. Regardless, surveyors and families may need more involvement in monitoring higher dementia prevalence facilities.

The relationship between nursing home staffing and resident safety outcomes: A systematic review of reviews

BACKGROUND

Resident safety is an important topic for nursing home practice with up to 33 % of residents subjected to an adverse event. In spite of a large evidence base examining the relationship between nursing home staffing and resident outcomes, the findings of several systematic reviews remain inconclusive and contradicting, possibly due to methodological shortcomings.

OBJECTIVE

The main aim of this review was to provide a comprehensive overview of the literature on nursing home staffing and its relationship with resident safety outcomes.

DESIGN

We undertook a systematic review of reviews. We searched Medline, CINAHL and Embase by the end of November 2022. Reviews were included if they assessed the relationship between nursing home staffing and resident safety outcomes using objective measures and data at resident level. Quality appraisal was conducted using the SIGN-checklist, but we did not exclude any reviews based on quality assessment. We used a narrative approach, tables and figures to summarize the findings.

RESULTS

We included 13 systematic reviews published between 2006 and 2022 building on primary evidence from 1977 to 2022. Twelve reviews investigated the relationship between nurse staffing and resident safety outcomes (187 unique primary studies), and one review focused on allied health professionals (28 primary studies). Five reviews originated as work to inform governmental recommendations on staffing. We found diverse approaches used to investigate the staffing-outcome relationship with regard to design, timeframe, operationalization, data-source and theoretical rationales guiding the studies. The most prominently reported resident safety outcomes were pressure ulcers and urinary tract infections. Commonly reported staffing measures included number and level of education of nursing home staff. Based on narrative summaries, staffing seems to have a favorable relationship with resident safety outcomes, but logic models explaining the mechanisms of this relationship were sparsely reported.

CONCLUSIONS

The existing literature shows methodological limitations that demand a change in research on the staffing-outcome relationship in the nursing home setting. Our work highlights the need for carefully designed primary studies that address the pertinent shortcomings by design, timeframe, operationalization, data-source and theoretical rationales. These future studies will allow to carefully examine the causal relationship between selected staffing measures and resident safety outcomes in further detail and serve as legitimate evidence bases to inform action plans for clinical practice and to evaluate staffing policies.

Creating age-friendly nursing homes: The time is now

The current global age-friendly movement supports older adults by promoting different policies and services. However, there is a dearth of attention to nursing home (NH) residents as part of age-friendly movements. The pioneering idea of an age-friendly health system, i.e., the "4 Ms" model is significant for NHs and formative for further developments; however, it does not identify unique components of NH care. This article aims to identify specific aspects of person-centered care in the literature to advance the development of a standardized conceptual framework. Along with residents, NH staff and administrators are integral parts of NHs. Incorporating the central role of caregivers, this study proposes a new "8 Ms" framework to describe the age-friendly NH. The traditional 4 Ms model notes that everything related to care matters to residents, along with care related to medication, mobility, and mentation. The proposed age-friendly framework introduces five additional "M," i.e., meaningful care, motivation, moderation, modification, and monitoring. This framework is proposed to advance education, training, clinical practice, research, and advocacy to promote quality of care in NHs. Application of the 8 Ms framework may yield multiple benefits, assuring good quality of care to residents, caregivers' job satisfaction, and supporting NH management in providing residents optimal care.

The effects of physicians on operational and financial performance in United States hospitals: staffing, human capital and knowledge spillovers

Purpose

The authors examine how physician staffing, human capital and knowledge spillovers are related to multiple dimensions of hospital operational and financial performance at the organizational level.

Design/methodology/approach

The authors use a data set assembled from multiple sources for more than 1,300 US hospitals and employ hierarchical linear regression to test this study’s hypotheses. The authors use multiple quality, efficiency and financial measures of performance for these hospitals.

Findings

The authors find that higher levels of staffing, skills and knowledge spillovers associated with physicians were positively associated with multiple dimensions of hospital performance. The authors find linear and nonlinear relationships between experience and performance, with the relationships primarily negative, and nonlinear relationships between spillovers and quality performance.

Practical implications

Hospital managers should consider increasing physician staffing levels if possible. In addition, the overall Final MIPS Score from the Centers for Medicare and Medicaid Services might be included as a factor in determining which physicians practice in a hospital. Finally, if possible, encouraging physicians to practice at multiple hospitals will likely be beneficial to hospital performance.

Originality/value

This study’s findings are original in that they explore how physician-specific staffing and human capital, which have received comparatively little attention in the literature, are related to several different dimensions of hospital-level operational and financial performance. To the best of the authors’ knowledge, this paper is also the first to examine the relationship between the construct of physician knowledge spillovers and hospital-level operational and financial performance.

Association of Staffing Instability With Quality of Nursing Home Care

IMPORTANCE

Recent work suggests that instability in nursing home staffing levels may be an important marker of nursing home quality. Whether that association holds when controlling for average staffing levels is unknown.

OBJECTIVE

To examine whether staffing instability, defined as the percentage of days below average staffing levels, is associated with nursing home quality when controlling for average staffing levels.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study of 14 717 nursing homes used the merged Centers for Medicare & Medicaid Services Payroll Based Journal, Minimum Data Set, Nursing Home Care Compare, and Long-Term-Care Focus data for fiscal years 2017 to 2019. Statistical analysis was performed from February 8 to November 14, 2022.

MAIN OUTCOMES AND MEASURES

Linear, random-effect models with state fixed effects and robust SEs were estimated for 12 quality indicators as dependent variables, percentage of below-average staffing days as independent variables, controlling for average staffing hours per resident-day for registered nurses, licensed practical nurses, and certified nurse aides. Below-average staffing days were defined as those 20% below the facility average, by staffing type. Quality indicators included deficiency citations; long-stay residents receiving an antipsychotic; percentage of high-risk long-stay residents with pressure ulcers (2 different measures for pressure ulcers were used); and percentage of long-stay residents with activities of daily living decline, mobility decline, emergency department visits, and hospitalizations; and short-stay residents with new antipsychotic medication, mobility decline, emergency department visits, and rehospitalizations.

RESULTS

For the 14 717 nursing homes in this study, the mean (SD) percentage of days with below-average staffing was 30.2% (12.0%) for registered nurses, 16.4% (11.3%) for licensed practical nurses, and 5.1% (5.3%) for certified nurse aides. Mean (SD) staffing hours per resident-day were 0.44 (0.40) for registered nurses, 0.80 (0.32) for licensed practical nurses, and 2.20 (0.50) for certified nurse aides. In regression models that included average staffing, a higher percentage of below-average staffing days was significantly associated with worse quality for licensed practical nurses in 10 of 12 models, with the largest association for decline of activities of daily living among long-stay residents (regression coefficient, 0.020; P < .001). A higher percentage of below-average staffing days was significantly associated with worse quality for certified nurse aides in 9 of 12 models, with the largest association for short-stay functioning (regression coefficient, 0.030; P = .01).

CONCLUSIONS AND RELEVANCE

This study suggests that holding average staffing levels constant, day-to-day staffing stability, especially avoiding days with low staffing of licensed practical nurses and certified nurse aides, is a marker of better quality of nursing homes. Future research should investigate the causes and potential solutions for instability in staffing in all facilities, including those that may appear well-staffed on average.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

The Impact of Recent State and Local Minimum Wage Increases on Nursing Facility Employment

Various U.S. states and municipalities raised their mandated minimum wages between 2017 and 2019. In some areas, minimum wages became high enough to bind for more professional workers, such as lower paid staff at nursing facilities. We add to the small prior literature on the effects of minimum wages on nursing facility staffing using novel establishment-level data on daily hours worked; these data allow us to examine changes in staffing hours along margins previously unexplored in the minimum wage literature. We find no evidence that minimum wage increases reduced hours worked among lower-paid nurses in nursing facilities. In contrast, we find that increases in state and local minimum wages increased hours worked per resident day by nursing assistants; increases occurred for the average of all days throughout the month and on weekend days. We also find that a higher minimum wage increased the share of days in the month that facilities meet at least 75% of the minimum recommended levels of staffing for nursing assistants. These results lessen concerns that minimum wage hikes may reduce the quality of resident care at nursing facilities.

12-month trajectory and predictors of affect balance in nursing home residents living with dementia

Objectives:Emotional expressions in late-stage dementia have traditionally been studied within a deficit paradigm. Moving the narrative of the dementia trajectory from a solely negative pathological experience to one that acknowledges the potential for positive experiences aligns with international recommendations for living well with dementia. The purpose of this study was to extend prior research by examining the pattern of well-being using affect balance, the ratio of positive to negative affect, in nursing home residents living with dementia over 12 months and its association to factors that could potentially influence resident well-being.Method:This study was a secondary analysis of baseline, 4 and 12-month data from a pragmatic clinical trial. A total of 536 residents with moderate to severe cognitive impairments from 55 nursing homes were included in the multivariable linear mixed model regression analyses.Results:Resident function, the number of registered nurse hours devoted to care in the facility, and the quality of staff interaction predicted higher affect balance over time after controlling for other variables.Conclusion:The findings provide support for the utility of affect balance as a meaningful outcome measure of well-being for persons living with dementia. In addition, results point to specific interventions (i.e. maintaining/improving resident function, providing adequate nurse staffing levels, and improving staff communications skills) that can serve as the focus for both research and practice to help residents live well with dementia. Clinicaltrials.gov (NCT03014570).

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

Objective

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

Methods

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

Results

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

Conclusion

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

Association of State COVID-19 Vaccine Mandates With Staff Vaccination Coverage and Staffing Shortages in US Nursing Homes

Importance

Several states implemented COVID-19 vaccine mandates for nursing home employees, which may have improved vaccine coverage but may have had the unintended consequence of staff departures.

Objective

To assess whether state vaccine mandates for US nursing home employees are associated with staff vaccination rates and reported staff shortages.

Design Setting and Participants

This cohort study performed event study analyses using National Healthcare Safety Network data from June 6, 2021, through November 14, 2021. Changes in weekly staff vaccination rates and reported staffing shortages were evaluated for nursing homes in states with mandates after the mandate announcement compared with changes in facilities in nonmandate states. An interaction between the mandates and county political leaning was considered. Data analysis was performed from February to March 2022.

Exposures

Weeks after announcement of a state's COVID-19 vaccine mandate.

Main Outcomes and Measures

Weekly percentage of all health care staff at a nursing home who received at least 1 COVID-19 vaccine dose, and a weekly indicator of whether a nursing home reported a staffing shortage.

Results

Among 38 study-eligible states, 26 had no COVID-19 vaccine mandate for nursing home employees, 4 had a mandate with a test-out option, and 8 had a mandate with no test-out option. Ten weeks or more after mandate announcement, nursing homes in states with a mandate and no test-out option experienced a 6.9 percentage point (pp) increase in staff vaccination coverage (95% CI, -0.1 to 13.9); nursing homes in mandate states with a test-out option experienced a 3.1 pp increase (95% CI, 0.5 to 5.7) compared with facilities in nonmandate states. No significant increases were detected in the frequency of reported staffing shortages after a mandate announcement in mandate states with or without test-out options. Increases in vaccination rates in states with mandates were larger in Republican-leaning counties (14.3 pp if no test-out option; 4.3 pp with option), and there was no evidence of increased staffing shortages.

Conclusions and Relevance

The findings of this cohort study suggest that state-level vaccine mandates were associated with increased staff vaccination coverage without increases in reported staffing shortages. Vaccination increases were largest when mandates had no test-out option and were also larger in Republican-leaning counties, which had lower mean baseline vaccination rates. These findings support the use of state mandates for booster doses for nursing home employees because they may improve vaccine coverage, even in areas with greater vaccine hesitancy.

Cost-quality tradeoff in nurse staffing: an exploration of USA hospitals facing market competition

Purpose

This research aims to explore the fine-grained relationships between nurse staffing and hospital operational performance with respect to care quality and operating costs. The authors also investigate the moderation effect of competition in local hospital markets on these relationships.

Design/methodology/approach

A six-year panel data is assembled from five separate sources to obtain information of 2,524 USA hospitals. Fixed-effect (FE) models are used to test the proposed hypotheses.

Findings

First, nurse staffing is initially associated with improved care quality until nurse staffing reaches a turning point, beyond which nurse staffing is associated with worse care quality. Second, a similar pattern applies to the relationship between nurse staffing and operating costs, although the turning point is at a much lower nurse staffing level. Third, market competition moderates the relationship between nurse staffing and care quality so that the turning point of nurse staffing will be higher when the degree of competition is higher. This shift of turning point is also observed in the relationship between nurse staffing and operating costs.

Practical implications

The study identifies three ranges of nurse staffing in which hospitals will likely experience simultaneous improvements, a tradeoff or simultaneous decline of care quality and operating costs when investing in more nursing capacity. Hospitals should adjust nurse staffing levels to the right directions to achieve better care or reduce operating costs.

Originality/value

Nurses constitute the largest provider group in hospitals and profoundly impact care quality and operating costs among all health care professionals. Optimizing the level of nurse staffing, therefore, can significantly impact the care quality and operating costs of hospitals.

Daily Variation in Nursing Home Staffing and Its Association With Quality Measures

IMPORTANCE

Average staffing measures are a focus of nursing homes' quality assessments and reporting. They may, however, mask daily variation in staffing, additional information that could be important for understanding nursing home quality and relative ranking.

OBJECTIVE

To examine daily variation in staffing, its association with quality, and whether daily variation provides information regarding quality ranking of nursing homes over and above the information provided by average staffing levels.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study included registered nurses (RNs) and certified nurse aide (CNAs) at 13 339 certified nursing homes throughout the United States during 2017 to 2018. Retrospective analyses of the Payroll-Based Journal, Medicare Cost Reports, and Nursing Home Care Compare were conducted. Data were analyzed from January 2017 to December 2018.

MAIN OUTCOMES AND MEASURES

Three measures of daily variation, ie, coefficient of variation (COV), total outlier days (TOD), and low outlier days (LOD), were calculated for RNs and CNAs. The association between these measures and quality rankings and other facility characteristics were evaluated.

RESULTS

A total of 13 339 nursing homes were included in this study, with 9476 (71%) for-profit facilities. The mean (SD) hours-per-resident-day were 0.41 (0.29) for RNs and 2.16 (0.49) for CNAs, and a mean (SD) 55% (26%) of residents were Medicaid beneficiaries. Outcome measures were as follows: mean (SD) COV, 0.5 (0.6) for RNs and 0.1 (0.1) for CNAs; mean (SD) TOD, 220 (69) for RNs and 44 (45) for CNAs; and mean (SD) LOD, 116 (45) for RNs and 22 (24) for CNAs. All 3 variation measures, for both RNs and CNAs, were significantly associated with both the 5-Star Quality Measures (COV among RNs, -0.014 [95% CI, -0.021 to -0.007]; P < .001; COV among CNAs: -0.004 [95% CI, -0.006 to -0.003]; P < .001; TOD among RNs, -3.79 [95% CI, -4.59 to -2.99]; P < .001; TOD among CNAs, -2.52 [95% CI, -3.08 to -1.96]; P < .001; LOD among RNs, -2.46 [95% CI, -3.03 to -1.88]; P < .001; LOD among CNAs, -1.29 [95% CI, -1.58 to -0.99]; P < .001) and the 5-Star Survey rankings (COV among RNs,-0.026 [95% CI, -0.033 to -0.019]; P < .001; COV among CNAs: -0.006 [95% CI, -0.007 to -0.004]; P < .001; TOD among RNs, -5.10 [95% CI, -5.97 to -4.23]; P < .001; TOD among CNAs, -4.16 [95% CI, -4.77 to -3.55]; P < .001; LOD among RNs, -3.04 [95% CI, -3.65 to -2.44]; P < .001; LOD among CNAs, -1.97 [95% CI, -2.29 to -1.65]; P < .001) published in Nursing Home Care Compare. Low κ values, ranging from 0.23 to 0.63, indicated that the variation measures add information about ranking to the information provided by average staffing measure.

CONCLUSIONS AND RELEVANCE

These findings highlight the importance of reporting daily variation in staffing to improve understanding of the relationship between staffing and quality. They suggest that 2 facilities with the same average staffing achieve different quality of resident care and survey ratings in association with on the day-to-day variation in staffing. Measures of daily staffing may enhance the value of Nursing Home Care Compare for nursing homes and others engaged in quality improvement and consumers searching for high quality nursing homes.

Facility characteristics and costs associated with meeting proposed minimum staffing levels in skilled nursing facilities

BACKGROUND

Federal minimum nurse staffing levels for skilled nursing facilities (SNFs) were proposed in 2019 U.S. Congressional bills. We estimated costs and personnel needed to meet the proposed staffing levels, and examined characteristics of SNFs not meeting these thresholds.

METHODS

This was a cross-sectional analysis of 2019Q4 payroll data, the Hospital Wage Index, and other administrative data for 14,964 Medicare and Medicaid-certified SNFs. We examined characteristics of SNFs not meeting proposed minimum thresholds: 4.1 total nursing hours per resident day (HPRD); 0.75 registered nurse (RN) HPRD; 0.54 licensed practical nurse (LPN) HPRD; and 2.81 certified nursing assistant (CNA) HPRD. For SNFs falling below the thresholds, we calculated the additional HPRD needed, along with the associated full-time equivalent (FTE) personnel and salary costs.

RESULTS

In 2019, 25.0% of SNFs met the minimum 4.1 total nursing HPRD, while 31.0%, 84.5%, and 10.7% met the RN, LPN, and CNA thresholds, respectively. Only 5.0% met all four categories. In adjusted analyses, factors most strongly associated with SNFs not meeting the proposed minimums were: higher Medicaid census, larger bed size, for-profit ownership, higher county SNF competition; and, for RNs specifically, higher community poverty and lower Medicare census. Rural SNFs were less likely to meet all categories and this was explained primarily by county SNF competition. We estimate that achieving the proposed federal minimums across SNFs nationwide would require an estimated additional 35,804 RN, 3509 LPN, and 116,929 CNA FTEs at $7.25 billion annually in salary costs based on current wage rates and prepandemic resident census levels.

CONCLUSIONS

Achieving proposed minimum nurse staffing levels in SNFs will require substantial financial investment in the workforce and targeted support of low-resource facilities. Extensive recruitment and retention efforts are needed to overcome supply constraints, particularly in the aftermath of the COVID-19 pandemic.

Medicare Beneficiary Factors Associated with Skilled Nursing Facility Lengths of Stay

The objectives of this study are (1) to identify beneficiary-level characteristics associated with skilled nursing facility (SNF) length of stay (LOS), and (2) to determine if significant differences in LOS exist for vulnerable populations at the individual level or among nursing homes that serve a disproportionate share of vulnerable populations. This study employed 2014-2015 Medicare Long-Term Care Minimum Data Set (MDS v3.0) assessment, fee-for-service claims and enrollment, and 2014 Nursing Home Compare data to examine SNF LOS in Medicare beneficiaries. We used a hierarchical linear model to identify which beneficiary-level characteristics are associated with SNF LOS, while controlling for facility-level characteristics. After controlling for beneficiary-and facility-level characteristics, we found dual eligibility, racial or ethnic minority, depression, and Alzheimer's disease to be associated with longer Medicare covered SNF stays. We found that facilities that served higher proportions of dually eligible individuals tended to have higher average LOS compared to other facilities.

Job Resignation in Nursing Homes During the COVID-19 Pandemic: The Role of Quality of Employer Communication

Limited research has examined coronavirus disease 2019 (COVID-19)-related work stressors experienced by nursing home (NH) employees and how these stressors may impact employees' decision to resign when taking organizational factors into account. Thus, the purpose of this study was to investigate whether quality of employer communication related to COVID-19 and staff preparedness to care for residents with COVID-19 can mediate the effects of COVID-19-related stressors on NH employees' (N = 1,730) decision to resign. Results from path analyses indicate that higher quality of communication and more optimal preparedness mediated the relationship between COVID-19-related stressors and likelihood of resignation. Specifically, higher levels of COVID-19-related stressors were indirectly associated with reduced likelihood of resigning through the paths of more optimal communication and preparedness. Findings underscore the importance of effective employer communication during emergencies in NHs.

Factors associated with nursing home direct care professionals' turnover intent during the COVID-19 pandemic

OBJECTIVE

To identify factors related to turnover intent among direct care professionals in nursing homes during the pandemic.

METHODS

Cross-sectional study with surveys administered via an employee management system to 809 direct care professionals (aides working in nursing homes). Single items assessed COVID-19-related work stress, preparedness to care for residents during COVID-19, job satisfaction, and intent to remain in job. A two-item scale assessed quality of organizational communication.

RESULTS

Path analysis demonstrated that only higher job satisfaction was associated with a higher likelihood of intent to remain in job. Higher quality of employer communication and greater preparedness were also associated with higher job satisfaction, but not with intent to remain. Higher quality communication and greater preparedness mediated the negative impact of COVID-19-related work stress on job satisfaction.

CONCLUSION

Provision of high-quality communication and training are essential for increasing job satisfaction and thus lessening turnover intent in nursing homes.

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

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

A systematic review of long-term care facility characteristics associated with COVID-19 outcomes

BACKGROUND/OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic has taken a disproportionate toll on long-term care facility residents and staff. Our objective was to review the empirical evidence on facility characteristics associated with COVID-19 cases and deaths.

DESIGN

Systematic review.

SETTING

Long-term care facilities (nursing homes and assisted living communities).

PARTICIPANTS

Thirty-six empirical studies of factors associated with COVID-19 cases and deaths in long-term care facilities published between January 1, 2020 and June 15, 2021.

MEASUREMENTS

Outcomes included the probability of at least one case or death (or other defined threshold); numbers of cases and deaths, measured variably.

RESULTS

Larger, more rigorous studies were fairly consistent in their assessment of risk factors for COVID-19 outcomes in long-term care facilities. Larger bed size and location in an area with high COVID-19 prevalence were the strongest and most consistent predictors of facilities having more COVID-19 cases and deaths. Outcomes varied by facility racial composition, differences that were partially explained by facility size and community COVID-19 prevalence. More staff members were associated with a higher probability of any outbreak; however, in facilities with known cases, higher staffing was associated with fewer deaths. Other characteristics, such as Nursing Home Compare 5-star ratings, ownership, and prior infection control citations, did not have consistent associations with COVID-19 outcomes.

CONCLUSION

Given the importance of community COVID-19 prevalence and facility size, studies that failed to control for these factors were likely confounded. Better control of community COVID-19 spread would have been critical for mitigating much of the morbidity and mortality long-term care residents and staff experienced during the pandemic. Traditional quality measures such as Nursing Home Compare 5-Star ratings and past deficiencies were not consistent indicators of pandemic preparedness, likely because COVID-19 presented a novel problem requiring extensive adaptation by both long-term care providers and policymakers.

Nursing assistants and resident satisfaction in long-term care: A systematic review

BACKGROUND

The number of nursing assistants (NAs) in the long-term care industry is on the rise, helping to service the needs of an increasingly aging population. Understanding influences on NAs service qualities and resident satisfaction is important to sustainable long-term care services. To date, the research evidence about NAs factors and resident satisfaction has not been synthesized. We aimed to address this gap in the evidence.

RESEARCH DESIGN AND METHODS

Utilizing a mixed-methods systematic review, we searched PubMed, PsycINFO, AgeLine, MEDLINE, Scopus, and Google Scholar databases for journal articles with primary data published from database inception to March 2021. Both qualitative and quantitative literature were considered and a narrative summary provided. Study reporting quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklists and Critical Appraisal Skills Programme Checklist.

RESULTS

A total of 25 articles, spanning 9 countries and regions, were included in the review. Study reporting quality was good. A positive relationship between aged-care resident satisfaction and NAs job satisfaction (n = 8) was identified. Resident satisfaction was enhanced through NA training programs (n = 7), quality of daily interaction with NAs (n = 6), and the overall contribution of NAs in promoting residents` experiences (n = 4) DISCUSSION: The current findings highlight the important role of NAs in improving resident care in long-term care settings. Nursing home administrators need to better understand the value of NAs and to provide supports for growth and development in their work. Continuing the professional development of NAs can not only improve their skills but also benefit resident satisfaction and organizational sustainability.

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.

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

BACKGROUND AND OBJECTIVES

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

DISCUSSION AND IMPLICATIONS

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

Expert nurse response to workforce recommendations made by the coronavirus commission for safety and quality in nursing homes

COVID-19 has exposed the longstanding internal problems in nursing homes and the weak structures and policies that are meant to protect residents. The Centers for Medicare and Medicaid Services convened the Coronavirus Commission for Safety and Quality in NHs in April, 2020 to address this situation by recommending steps to improve infection prevention and control, safety procedures, and the quality of life of residents in nursing homes. The authors of this paper respond to the Final Report of the Commission and put forth additional recommendations to federal policymakers for meaningful nursing home reform: 1) ensuring 24/7 registered nurse (RN) coverage and adequate compensation to maintain total staffing levels that are based on residents’ care needs; 2) ensuring RNs have geriatric nursing and leadership competencies; 3) increasing efforts to recruit and retain the NH workforce, particularly RNs; and 4) supporting care delivery models that strengthen the role of the RN for quality resident-centered care.

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.

Nurse Staffing and Coronavirus Infections in California Nursing Homes

In the United States, 1.4 million nursing home residents have been severely impacted by the COVID-19 pandemic with at least 25,923 resident and 449 staff deaths reported from the virus by June 1, 2020. The majority of residents have chronic illnesses and conditions and are vulnerable to infections and many share rooms and have congregate meals. There was evidence of inadequate registered nurse (RN) staffing levels and infection control procedures in many nursing homes prior to the outbreak of the virus. The aim of this study was to examine the relationship of nurse staffing in California nursing homes and compare homes with and without COVID-19 residents. Study data were from both the California and Los Angeles Departments of Public Health and as well as news organizations on nursing homes reporting COVID-19 infections between March and May 4, 2020. Results indicate that nursing homes with total RN staffing levels under the recommended minimum standard (0.75 hours per resident day) had a two times greater probability of having COVID-19 resident infections. Nursing homes with lower Medicare five-star ratings on total nurse and RN staffing levels (adjusted for acuity), higher total health deficiencies, and more beds had a higher probability of having COVID-19 residents. Nursing homes with low RN and total staffing levels appear to leave residents vulnerable to COVID-19 infections. Establishing minimum staffing standards at the federal and state levels could prevent this in the future.

Appropriate Nurse Staffing Levels for U.S. Nursing Homes

US nursing homes are required to have sufficient nursing staff with the appropriate competencies to assure resident safety and attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident. Minimum nurse staffing levels have been identified in research studies and recommended by experts. Beyond the minimum levels, nursing homes must take into account the resident acuity to assure they have adequate staffing levels to meet the needs of residents. This paper presents a guide for determining whether a nursing home has adequate and appropriate nurse staffing. We propose five basic steps to: (1) determine the collective resident acuity and care needs, (2) determine the actual nurse staffing levels, (3) identify appropriate nurse staffing levels to meet residents care needs, (4) examine evidence regarding the adequacy of staffing, and (5) identify gaps between the actual staffing and the appropriate nursing staffing levels based on resident acuity. Data sources and specific methodologies are analyzed, compared, and recommended. The goal is to assist nursing home nurses and administrators to ensure adequate nursing home staffing levels that protect resident health, safety, and well-being.

Nursing practice environment and care quality in nursing homes

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

Family Satisfaction With Nursing Home Care: Findings and Implications From Two State Comparison

Family satisfaction, while recognized as important, is frequently missing from validated measures of long-term care quality. This is the first study to compare family satisfaction across two states using validated measures and to compare the organizational and structural factors associated with higher family satisfaction with nursing home care. Data sources are family satisfaction surveys from Minnesota (MN) and Ohio (OH), linked to facility characteristics from Certification and Survey Provider Enhanced Reports (CASPER) for both states (N = 378 facilities for MN; N = 926 facilities for OH). Activities and food were among lowest rated items in both states. Relationships with staff were the highest rated domain. Higher occupancy rates, smaller facility size, and non-profit ownership consistently predicted better satisfaction in both states. Our findings show consistent organizational factors associated with family satisfaction and provide further evidence to the validity of family satisfaction as a person-centered measure of quality. This lays the foundation for tool development on the national level.

Nurse Aide Retention in Nursing Homes

Background and Objectives

The association of nurse aide retention with three quality indicators is examined. Retention is defined as the proportion of staff continuously employed in the same facility for a defined period of time.

Research Design and Methods

Data used in this investigation came from survey responses from 3,550 nursing facilities, Certification and Survey Provider Enhanced Reporting data, and the Area Resource File. Staffing characteristics, quality indicators, facility, and market information from these data sources were all measured in 2016. Nurse aide retention was measured at 1, 2, and 3 years of employment. The quality indicators examined were a count of all deficiency citations, quality of care deficiency citations, and J, K, L deficiency citations. Negative binomial regression analyses were used to study the associations between the three different retention measures and these three quality indicators.

Results

The 1-, 2-, and 3-year nurse aide retention measures were 53.2%, 41.4%, and 36.1%, respectively. The regression analyses show low levels of retention to be generally associated with poor performance on the three deficiency citation quality indicators examined.

Discussion and Implications

The research presented starts to provide information on nurse aide retention as an important workforce challenge and its potential impact on quality. Retention may be an additional staffing characteristic of nursing facilities with substantial policy and practice relevance.

Restoring trust: COVID-19 and the future of long-term care in Canada

The Royal Society of Canada Task Force on COVID-19 was formed in April 2020 to provide evidence-informed perspectives on major societal challenges in response to and recovery from COVID-19. The Task Force established a series of working groups to rapidly develop policy briefings, with the objective of supporting policy makers with evidence to inform their decisions. This paper reports the findings of the COVID-19 Long-Term Care (LTC) working group addressing a preferred future for LTC in Canada, with a specific focus on COVID-19 and the LTC workforce. First, the report addresses the research context and policy environment in Canada’s LTC sector before COVID-19 and then summarizes the existing knowledge base for integrated solutions to challenges that exist in the LTC sector. Second, the report outlines vulnerabilities exposed because of COVID-19, including deficiencies in the LTC sector that contributed to the magnitude of the COVID-19 crisis. This section focuses especially on the characteristics of older adults living in nursing homes, their caregivers, and the physical environment of nursing homes as important contributors to the COVID-19 crisis. Finally, the report articulates principles for action and nine recommendations for action to help solve the workforce crisis in nursing homes.

Small is beautiful? Explaining resident satisfaction in Swedish nursing home care

BACKGROUND

Resident satisfaction is an important aspect of nursing home quality. Despite this, few studies have systematically investigated what aspects of nursing home care are most strongly associated with satisfaction. In Sweden, a large number of processual and structural measures are collected to describe the quality of nursing home care, though the impact of these measures on outcomes including resident satisfaction is poorly understood.

METHODS

A cross-sectional analysis of data collected in two nationally representative surveys of Swedish eldercare quality using multi-level models to account for geographic differences.

RESULTS

Of the factors examined, nursing home size was found to be the most important predictor of resident satisfaction, followed by the amount of exercise and activities offered by the nursing home. Measures of individualized care processes, ownership status, staffing ratios, and staff education levels were also weakly associated with resident satisfaction. Contrary to previous research, we found no clear differences between processual and structural variables in terms of their association with resident satisfaction.

CONCLUSIONS

The results suggest that of the investigated aspects of nursing home care, the size of the nursing home and the amount activities offered to residents were the strongest predictors of satisfaction. Investigation of the mechanisms behind the higher levels of satisfaction found at smaller nursing homes may be a fruitful avenue for further research.

U.S. Nursing Home Violations of International and Domestic Human Rights Standards

We present a review of the international covenants and conventions and U.S. domestic laws and regulations that are designed to protect nursing home residents in the United States. Based on a review of research studies, government reports, and news reports, we found extensive evidence of widespread and systematic abuse and neglect of nursing home residents in the United States that needs urgent government action to protect the basic human rights of residents.

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.

Exploring social-based discrimination among nursing home certified nursing assistants

Certified nursing assistants (CNAs) provide the majority of direct care to nursing home residents in the United States and, therefore, are keys to ensuring optimal health outcomes for this frail older adult population. These diverse direct care workers, however, are often not recognized for their important contributions to older adult care and are subjected to poor working conditions. It is probable that social-based discrimination lies at the core of poor treatment toward CNAs. This review uses perspectives from critical social theory to explore the phenomenon of social-based discrimination toward CNAs that may originate from social order, power, and culture. Understanding manifestations of social-based discrimination in nursing homes is critical to creating solutions for severe disparity problems among perceived lower-class workers and subsequently improving resident care delivery.

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

Background

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

Aim

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

Objectives

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

Data sources

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

Design

Mapping review and rapid, systematic evidence syntheses.

Setting

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

Review methods

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Study registration

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

Funding

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

Failure to Meet Nurse Staffing Standards: A Litigation Case Study of a Large US Nursing Home Chain

Large for-profit nursing home chains in the United States have generally reported low nurse staffing levels. This historical case study examined a class action litigation case regarding staffing levels, resident rights, and quality outcomes in 12 Arkansas nursing homes owned by a large for-profit chain. The questions were as follows: (1) How did the residents’ care needs compare with actual nurse staffing levels? (2) How did the staffing levels compare with federal and state nurse staffing requirements and professional staffing standards? (3) Did the facilities comply with state and federal residents’ rights and quality of care requirements? The findings showed staffing levels marginally above state minimum standards, staffing shortages that violated state standards, staffing levels not adjusted for resident acuity, and shortages that resulted in omitted care. Staffing levels were lower than needed according to nursing directors, lower than average facilities in the state, and lower than professional standards. The findings showed many resident grievances regarding basic care and residents’ rights, clinical measures of poor quality, and state deficiencies. A large settlement was agreed on to compensate the residents. The case shows that chain’s management, as well as the regulatory system, failed to ensure adequate staffing levels that took into account regulatory requirements and professional standards and resulted in violations of residents’ rights, health, safety, and well-being.

Examination of the New Short-Stay Nursing Home Quality Measures: Rehospitalizations, Emergency Department Visits, and Successful Returns to the Community

In 2016, the Centers for Medicare & Medicaid Services (CMS) introduced 3 new quality measures (QMs) to its report card, Nursing Home Compare (NHC). These measures—rehospitalizations, emergency department visits, and successful discharges to the community—focus on short-stay residents. We offer a first analysis of nursing homes’ performance in terms of these new measures. We examined their properties and distribution across nursing homes using descriptive statistics and regression models. We found that, similar to other QMs, performance varies across the country, and that there is very minimal correlation between these 3 new QMs as well as between these QMs and other NHC QMs. Regression models reveal that better performance on these QMs tends to be associated with fewer deficiencies, higher staffing and more skilled staffing, nonprofit ownership, and lower proportion of Medicaid residents. Other characteristics are associated with better performance for some but not all 3 QMs. We also found improvement in all 3 QMs in the second year of publication. This study contributes to the validity of these measures by demonstrating their relationship to these structural QMs. It also suggests that these QMs are important by demonstrating their large variation across the country, suggesting substantial room for improvement, and finding that nursing homes are already responding to the incentives created by publication of these QMs.

Are Recessions Good for Staffing in Nursing Homes?

The quality and cost of care in nursing homes depend critically on the number and types of nurses. Recent research suggests that the nursing supply adjusts to macroeconomic conditions. However, prior work has failed to consider the effect of macroeconomic conditions on demand for nurses through the effect on revenues. We test how county-level unemployment rates affect direct-care staffing rates in nursing homes using California data. We exploit the wide variation in the unemployment rates across counties and over time in 2005-2012. We also test whether there are heterogeneous effects of unemployment rates by facility size, staffing level, and profit status. We find that as unemployment rates increase, staffing by registered nurses (RNs) decreases but staffing by licensed practical nurses (LPNs) increases. The increase in LPNs is larger in large nursing homes, nursing homes with higher staffing levels, and in for-profit nursing homes. We also find that as unemployment rates increase, nursing home revenue decreases. While the effect of macroeconomic conditions on nursing supply may be important for cost and quality of care, the mechanism is not simple, direct, or homogeneous for all types of nurses and nursing homes.

Application of the European quality indicators for psychosocial dementia care in long-term care facilities in the Asia-Pacific region: a pilot study

OBJECTIVES

An Asia-Pacific regional collaboration group conducted its first multi-country research project to determine whether or not European quality indicators (QIs) for psychosocial care in dementia could be implemented as a valid tool in residential aged care across seven Asia-Pacific sites (Australia, Hong Kong Special Administrative Region, Mainland China, Malaysia, Singapore, South Korea, and Thailand).

METHOD

Following the European QI protocol, auditing and data extraction of medical records of consenting residents with dementia were conducted by trained auditors with relevant health care backgrounds. Detailed field notes by the auditors were also obtained to describe the characteristics of the participating care facilities, as well as key issues and challenges encountered, for each of the 12 QIs.

RESULTS

Sixteen residential care facilities in the seven Asia-Pacific sites participated in this study. Data from 275 residents' records revealed each of the 12 Qis' endorsement varied widely within and between the study sites (0%-100%). Quality of the medical records, family and cultural differences, definitions and scoring of certain indicators, and time-consuming nature of the QI administration were main concerns for implementation.

CONCLUSION

Several items in the European QIs in the current format were deemed problematic when used to measure the quality of psychosocial care in the residential aged care settings in participating Asia-Pacific countries. We propose refinements of the European QIs for the Asian-Pacific context, taking into account multiple factors identified in this study. Our findings provide crucial insights for future research and implementation of psychosocial dementia care QIs in this region.

Review of Nutrition Screening and Assessment Practices for Long-Term Care Residents

The older adult population in Canada is growing, creating a greater demand for long-term care (LTC) facilities. Seniors living in LTC are more vulnerable to malnutrition, making it important to implement nutrition screening tools on a routine basis. The purpose of this study was to explore the practices of Registered Dietitians (RDs) related to nutritional screening, nutritional assessment, and follow-ups conducted within LTC facilities. This study also explored possible barriers hindering the application of these practices. Nine RDs from two health regions in Southern Saskatchewan completed a phone interview to address nutrition care practices/policies and barriers in LTC facilities. Results showed a considerable amount of variability in nutrition care practices for screening and assessment with lack of time identified as the greatest barrier. These findings highlight the importance of having consistent policies and a sufficient amount of RDs available in LTC facilities to provide the expected level of nutrition care for residents.

Clinicians' Perspectives of Patient Engagement in Post-Acute Care: A Social Ecological Approach

Aims

To identify rehabilitation providers' perspectives on barriers and facilitators of patient engagement in hip fracture patients in skilled nursing facilities (SNFs) within the social ecological model.

Methods

We conducted 13 focus groups in SNFs throughout Los Angeles County comprised of rehabilitation staff (n=99). Focus groups were audio-recorded and transcribed. A secondary analysis of themes related to patient engagement were identified and organized within the social ecological model.

Results

Clinicians identified barriers and facilitators of patient engagement across all levels of the social ecological model: public policy (e.g., insurance), organizational (e.g., facility culture), interpersonal (e.g., clinicians fostering self-reflection), and intrapersonal (e.g., patients' anxiety).

Conclusions

Examining barriers and facilitators to patient engagement has highlighted areas which need to be sustained and improved. Thus, these findings future efforts to enhance patient engagement in order can to optimize patient healthcare decisions.

Nursing Home Physicians Discuss Caring for Elderly Residents: An Exploratory Study

Malgré la complexité croissante des soins en foyers de soins de longue durée, le rôle des médecins dans la prestation des soins aux résidents a été peu étudié. Cette étude exploratoire internationale visait à mieux comprendre les rôles des médecins, leurs responsabilités et leurs tâches, ainsi qu’à explorer les caractéristiques uniques de la pratique médicale dans les foyers de soins de longue durée. Des entrevues ont été menées avec 18 médecins. Ces médecins ont mentionné qu’ils contribuaient fortement à la qualité des soins pour les résidents, en clarifiant les objectifs des soins, en prenant des mesures pour réduire les hospitalisations et les prescriptions de médicaments non nécessaires, et en contribuant à la formation du personnel. Les pratiques en foyers de soins de longue durée impliquaient les médecins au centre de réseaux de relations qui assuraient non seulement une meilleure qualité des soins médicaux, mais aussi une satisfaction professionnelle chez les médecins. L’importance de ces relations est telle qu’elle permettait d’aller au-delà des démarcations traditionnelles entre le domaine médical et le domaine social, et mettait en évidence qu’une bonne pratique médicale implique de bonnes pratiques sociales. Considérant la nature exploratoire de l’étude, les auteurs recommandent que de futures recherches soient menées pour mieux comprendre les dimensions relationnelles associées à la pratique de la médecine en foyers de soins de longue durée.

Relationships between work outcomes, work attitudes and work environments of health support workers in Ontario long-term care and home and community care settings

BACKGROUND

Our overarching study objective is to further our understanding of the work psychology of Health Support Workers (HSWs) in long-term care and home and community care settings in Ontario, Canada. Specifically, we seek novel insights about the relationships among aspects of these workers' work environments, their work attitudes, and work outcomes in the interests of informing the development of human resource programs to enhance elder care.

METHODS

We conducted a path analysis of data collected via a survey administered to a convenience sample of Ontario HSWs engaged in the delivery of elder care over July-August 2015.

RESULTS

HSWs' work outcomes, including intent to stay, organizational citizenship behaviors, and performance, are directly and significantly related to their work attitudes, including job satisfaction, work engagement, and affective organizational commitment. These in turn are related to how HSWs perceive their work environments including their quality of work life (QWL), their perceptions of supervisor support, and their perceptions of workplace safety.

CONCLUSIONS

HSWs' work environments are within the power of managers to modify. Our analysis suggests that QWL, perceptions of supervisor support, and perceptions of workplace safety present particularly promising means by which to influence HSWs' work attitudes and work outcomes. Furthermore, even modest changes to some aspects of the work environment stand to precipitate a cascade of positive effects on work outcomes through work attitudes.