Nursing home staffing, turnover, and case mix

New Dimensions of Staffing Patterns in Nursing Homes and Nursing Home Quality: Comparing Staffing Instability to Staffing Turnover

OBJECTIVE

This study examines how measures of staffing-turnover and instability-are associated with one another and how they independently contribute to quality of care in nursing homes.

DESIGN

Cross-sectional analysis of 2021-2022 administrative data. Data included the Payroll Based Journal for daily staffing information, merged with Nursing Home Care Compare (NHCC) data for nursing home characteristics, total staffing turnover, and nursing home quality.

SETTING AND PARTICIPANTS

A total of 11,840 nursing homes nationally reporting data on daily staffing and staffing turnover.

METHODS

We explored correlations between measures of staffing and estimated facility-level regression models with robust standard errors. The dependent variables were indicators of nursing home quality included in the NHCC 5-star ratings. The independent variables of interest were average total staffing hours per resident-day, total staffing turnover, and total staffing instability.

RESULTS

For the 11,840 nursing homes in the study, there was a weak positive correlation between turnover and instability, with some overlap between nursing homes with high instability and high turnover. Regression analysis revealed that staffing instability and turnover contributed independently to nursing home quality, with instability having a stronger association with some measures of quality and turnover with others. Staffing instability was positively and more strongly associated with long-stay residents' decline in activities of daily living levels and receipt of antipsychotic drugs and short-stay residents' functioning at discharge. Turnover was positively and more strongly associated with long-stay residents' prevalence of pressure ulcers and worsening mobility, and short-stay residents' hospitalizations.

CONCLUSION AND IMPLICATIONS

Instability and turnover in total nursing home staffing independently contribute to nursing home quality. This suggests that adding measures of staffing instability to the existing measures of average staffing and staff turnover in NHCC may enhance the report card's value for providers engaged in quality improvement and consumers searching for high-quality nursing homes.

Impact of using a centralized matching process on nursing home staffing

OBJECTIVE

To examine the effectiveness of adopting a novel centralized matching process for reducing staff shortages in Massachusetts nursing homes during the COVID-19 pandemic.

METHODS

This study involved several datasets and 216 Massachusetts nursing homes that used a novel online portal to enter demand for nursing staff from May 2020 to April 2021.

RESULTS

There were significant associations between the staff-to-resident ratio and demand entries lagged by three and four weeks, and no significant associations between the staff-to-resident ratio and demand entries lagged by one and two weeks. In contrast, we found significant associations between the staff-to-resident ratio and the number of generated staff matches lagged by one, two and three weeks, with larger impacts overall.

CONCLUSION

This study shows how adopting a centralized matching process may expedite and increase improvement in the staff-to-resident ratio in nursing homes, compared with the setup in which nursing homes need to seek nurses on their own.

Nursing factors associated with length of stay and readmission rate of the elderly residents from nursing home based on LTCfocus database

OBJECTIVES

Nursing factors have been found to be associated with a reduction in readmission rates. Nevertheless, few attentions have been given to the effect of nursing factors on nursing home (NH) residents. This study was to assess the impact of nursing factors on the hospital readmissions and length of stay (LOS) of the elderly residents from the NH.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Data were extracted from the NH of the LTCFocus.org data set between 2011 and 2018. The study included residents aged ≥55 years who were admitted to NH in the United States, following a hospitalization event. The nursing factors included facility-level data elements and medical care personnel. An unsupervised machine learning algorithm (K-means) was used to cluster NH according to readmission rate and LOS. Multivariate logistic regression analysis was performed.

RESULTS

This study consisted of 107,000 NH-year observations. The median readmission rate was 17%, with a median LOS was 28.00 days. Three clusters were identified: cluster 1 was a high readmission rate with high LOS, cluster 2 was a low readmission rate with low LOS, and cluster 3 was a high readmission rate with low LOS. Multifacility and admission/bed were associated with a reduction in readmission rate and LOS in both cluster 1 vs cluster 2 and cluster 3 vs cluster 2. The special care unit and registered nurses' ratio were associated with decreased readmission rate and LOS in cluster 1 vs cluster 2. Total beds and Alzheimer unit decreased the readmission rate and LOS, whereas certified nursing assistant increased the readmission rate and LOS in cluster 3 vs cluster 2. NH for profit was associated with elevated readmission rate and LOS in cluster 1 vs cluster 2 and decreased readmission rate and LOS in cluster 3 vs cluster 2. Based on the subgroup analysis, the certified nursing assistant decreased readmission rate and LOS in cluster 1 vs cluster 2 and increased readmission rate and LOS in cluster 3 vs cluster 2 (all P < 0.005).

CONCLUSION

This study indicates the importance of the improvement of nurse number and level and the inputs of facility characteristics in NH.

Associations of infection control measures and norovirus outbreak outcomes in healthcare settings: a systematic review and meta-analysis

BACKGROUND

Although most norovirus outbreaks in high-income countries occur in healthcare facilities, information on associations between control measures and outbreak outcomes in these settings is lacking.

METHODS

We conducted a systematic review/meta-analysis to assess associations between norovirus outbreak control measures and outcomes in hospitals and long-term care facilities (LTCFs), globally. Using regression analyses stratified by setting (hospital/LTCF), we compared durations, attack rates, and case counts for outbreaks in which control measures were reportedly implemented to those in which they were not.

RESULTS

We identified 102 papers describing 162 norovirus outbreaks. Control measures were reportedly implemented in 118 (73%) outbreaks and were associated with 0.6 (95% CI: 0.3-1.1) times smaller patient case counts and 0.7 (95% CI: 0.4, 1.0) times shorter durations in hospitals but 1.5 (95% CI: 1.1-2.2), 1.5 (95% CI: 1.0-2.1) and 1.6 (95% CI: 1.0-2.6) times larger overall, resident and staff case counts, respectively, and 1.4 (95% CI: 1.0-2.0) times longer durations in LTCFs.

CONCLUSIONS

Reported implementation of control measures was associated with smaller/shorter outbreaks in hospitals but larger/longer outbreaks in LTCFs. Control measures were likely implemented in response to larger/longer outbreaks in LTCFs, rather than causing them. Prospective observational or intervention studies are needed to determine effectiveness.

Changing landscape of nursing homes serving residents with dementia and mental illnesses

OBJECTIVE

Nursing homes (NHs) are serving an increasing proportion of residents with cognitive issues (e.g., dementia) and mental health conditions. This study aims to: (1) implement unsupervised machine learning to cluster NHs based on residents' dementia and mental health conditions; (2) examine NH staffing related to the clusters; and (3) investigate the association of staffing and NH quality (measured by the number of deficiencies and deficiency scores) in each cluster.

DATA SOURCES

2009-2017 Certification and Survey Provider Enhanced Reporting (CASPER) were merged with LTCFocUS.org data on NHs in the United States.

STUDY DESIGN

Unsupervised machine learning algorithm (K-means) clustered NHs based on percent residents with dementia, depression, and serious mental illness (SMI, e.g., schizophrenia, anxiety). Panel fixed-effects regressions on deficiency outcomes with staffing-cluster interactions were conducted to examine the effects of staffing on deficiency outcomes in each cluster.

DATA EXTRACTION METHODS

We identified 110,463 NH-year observations from 14,671 unique NHs using CASPER data.

PRINCIPAL FINDINGS

Three clusters were identified: low dementia and mental illnesses (Postacute Cluster); high dementia and depression, but low SMI (Long-stay Cluster); and high dementia and mental illnesses (Cognitive-mental Cluster). From 2009 to 2017, the number of Postacute Cluster NHs increased from 3074 to 5719, while the number of Long-stay Cluster NHs decreased from 6745 to 3058. NHs in Long-stay/Cognitive-mental Clusters reported slightly lower nursing staff hours in 2017. Regressions suggested the effect of increasing staffing on reducing deficiencies is statistically similar across NH clusters. For example, 1 hour increase in registered nurse hours per resident day was associated with -0.67 (standard error [SE] = 0.11), -0.88 (SE = 0.12), and -0.97 (SE = 0.15) deficiencies in Postacute Cluster, Long-stay Cluster, and Cognitive-mental Cluster, respectively.

CONCLUSIONS

Unsupervised machine learning detected a changing landscape of NH serving residents with dementia and mental illnesses, which requires assuring staffing levels and trainings are suited to residents' needs.

COVID-19 Cases and Death in Nursing Homes: The Role of Racial and Ethnic Composition of Facilities and Their Communities

OBJECTIVES

To examine the extent to which the racial and ethnic composition of nursing homes (NHs) and their communities affects the likelihood of COVID-19 cases and death in NHs, and whether and how the relationship between NH characteristics and COVID-19 cases and death varies with the racial and ethnic composition of the community in which an NH is located.

METHODS AND DESIGN

Centers for Medicare & Medicare Services Nursing Home COVID-19 data were linked with other NH- or community-level data (eg, Certification and Survey Provider Enhanced Reporting, Minimum Data Set, Nursing Home Compare, and the American Community Survey).

SETTING AND PARTICIPANTS

NHs with more than 30 occupied beds (N=13,123) with weekly reported NH COVID-19 records between the weeks of June 7, 2020, and August 23, 2020. Measurements and model: Weekly indicators of any new COVID-19 cases and any new deaths (outcome variables) were regressed on the percentage of black and Hispanic residents in an NH, stratified by the percentage of blacks and Hispanics in the community in which the NH was located. A set of linear probability models with NH random effects and robust standard errors were estimated, accounting for other covariates.

RESULTS

The racial and ethnic composition of NHs and their communities were both associated with the likelihood of having COVID-19 cases and death in NHs. The racial and ethnic composition of the community played an independent role in the likelihood of COVID-19 cases and death in NHs, even after accounting for the COVID-19 infection rate in the community (ie, daily cases per 1000 people in the county). Moreover, the racial and ethnic composition of a community modified the relationship between NH characteristics (eg, staffing) and the likelihoods of COVID-19 cases and death.

CONCLUSIONS AND IMPLICATIONS

To curb the COVID-19 outbreaks in NHs and protect vulnerable populations, efforts may be especially needed in communities with a higher concentration of racial and ethnic minorities. Efforts may also be needed to reduce structural racism and address social risk factors to improve quality of care and population health in communities of color.

High Nursing Staff Turnover In Nursing Homes Offers Important Quality Information

Nursing staff turnover has long been considered an important indicator of nursing home quality. However, turnover has never been reported on the Nursing Home Compare website, likely because of the lack of adequate data. On July 1, 2016, the Centers for Medicare and Medicaid Services began collecting auditable payroll-based daily staffing data for US nursing homes. We used 492 million nurse shifts from these data to calculate a novel turnover metric representing the percentage of hours of nursing staff care that turned over annually at each of 15,645 facilities. Mean and median annual turnover rates for total nursing staff were roughly 128 percent and 94 percent, respectively. Turnover rates were correlated with facility location, for-profit status, chain ownership, Medicaid patient census, and star ratings. Disseminating facilities' nursing staff turnover rates on Nursing Home Compare could provide important quality information for policy makers, payers, and consumers, and it may incentivize efforts to reduce turnover.

Long-Term Care Planning, Preparedness, and Response Among Rural Long-Term Care Providers

OBJECTIVE

Rural Long-term Care (LTC) providers face unique challenges when planning, preparing for, and responding to disasters. We sought to better understand challenges and identify best practices for LTC in rural areas.

METHODS

Case studies including key informant interviews and site visits were conducted with LTC staff and emergency planning, preparedness, and response partners in three rural communities. Themes were identified across sites using inductive coding.

RESULTS

Communication across disaster phases continues to be a challenge for LTC providers in rural communities for all disaster types. Communication challenges limit LTC providers' ability to address patient needs during emergencies and limit the resilience of providers and patients to future disasters. Limited coordination among local leadership and LTC providers prevents dissemination of information, resources, and services, and slows response and recovery time. Including LTC providers as stakeholders in planning and exercises may improve communication and coordination.

CONCLUSION

More than two decades into efforts to increase preparedness of health care systems to all hazards, rural LTC facilities still face challenges related to communication and coordination. Agencies at the federal, state, and local level should include input from rural LTC stakeholders to address gaps in communication and coordination and increase their disaster resilience.

Shortages of Staff in Nursing Homes During the COVID-19 Pandemic: What are the Driving Factors?

Objectives

During the Coronavirus Disease 2019 (COVID-19) pandemic, US nursing homes (NHs) have been under pressure to maintain staff levels with limited access to personal protection equipment (PPE). This study examines the prevalence and factors associated with shortages of NH staff during the COVID-19 pandemic.

Design

We obtained self-reported information on staff shortages, resident and staff exposure to COVID-19, and PPE availability from a survey conducted by the Centers for Medicare and Medicaid Services in May 2020. Multivariate logistic regressions of staff shortages with state fixed-effects were conducted to examine the effect of COVID-19 factors in NHs.

Setting and Participants

11,920 free-standing NHs.

Measures

The dependent variables were self-reported shortages of licensed nurse staff, nurse aides, clinical staff, and other ancillary staff. We controlled for NH characteristics from the most recent Nursing Home Compare and Certification and Survey Provider Enhanced Reporting, market characteristics from Area Health Resources File, and state Medicaid reimbursement calculated from Truven data.

Results

Of the 11,920 NHs, 15.9%, 18.4%, 2.5%, and 9.8% reported shortages of licensed nurse staff, nurse aides, clinical staff, and other staff, respectively. Georgia and Minnesota reported the highest rates of shortages in licensed nurse and nurse aides (both >25%). Multivariate regressions suggest that shortages in licensed nurses and nurse aides were more likely in NHs having any resident with COVID-19 (adjusted odds ratio [AOR] = 1.44, 1.60, respectively) and any staff with COVID-19 (AOR = 1.37, 1.34, respectively). Having 1-week supply of PPE was associated with lower probability of staff shortages. NHs with a higher proportion of Medicare residents were less likely to experience shortages.

Conclusions/Implications

Abundant staff shortages were reported by NHs and were mainly driven by COVID-19 factors. In the absence of appropriate staff, NHs may be unable to fulfill the requirement of infection control even under the risk of increased monetary penalties.

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.

Leadership, Staff Empowerment, and the Retention of Nursing Assistants: Findings From a Survey of U.S. Nursing Homes

OBJECTIVES

We examined the relationship between nursing assistant (NA) retention and a measure capturing nursing home leadership and staff empowerment.

DESIGN

Cross-sectional study using nationally representative survey data.

SETTING AND PARTICIPANTS

Data from the Nursing Home Culture Change 2016-2017 Survey with nursing home administrator respondents (N = 1386) were merged with facility-level indicators.

METHODS

The leadership and staff empowerment practice score is an index derived from responses to 23 survey items and categorized as low, medium, and high. Multinomial logistic regression weighted for sample design and to address culture-change selection bias identified factors associated with 4 categories of 1-year NA retention: 0% to 50%, 51% to 75%, 76% to 90%, and 91% to 100%.

RESULTS

In an adjusted model, greater leadership and staff empowerment levels were consistently associated with high (76%-90% and 91%-100%) relative to low (0%-50%) NA retention. Occupancy rate, chain status, licensed practical nurse and certified nursing assistant hours per day per resident, nursing home administrator turnover, and the presence of a union were also significantly associated with higher categories of retention (vs low retention).

CONCLUSIONS AND IMPLICATIONS

Modifiable leadership and staff empowerment practices are associated with NA retention. Associations are most significant when examining the highest practice scores and retention categories. Nursing homes seeking to improve NA retention might look to leadership and staff empowerment practice changes common to culture change.

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.

Cost and Return on Investment of a Work-Family Intervention in the Extended Care Industry: Evidence From the Work, Family, and Health Network

OBJECTIVE

To estimate the cost and return on investment (ROI) of an intervention targeting work-family conflict (WFC) in the extended care industry.

METHODS

Costs to deliver the intervention during a group-randomized controlled trial were estimated, and data on organizational costs-presenteeism, health care costs, voluntary termination, and sick time-were collected from interviews and administrative data. Generalized linear models were used to estimate the intervention's impact on organizational costs. Combined, these results produced ROI estimates. A cluster-robust confidence interval (CI) was estimated around the ROI estimate.

RESULTS

The per-participant cost of the intervention was $767. The ROI was -1.54 (95% CI: -4.31 to 2.18). The intervention was associated with a $668 reduction in health care costs (P < 0.05).

CONCLUSIONS

This paper builds upon and expands prior ROI estimation methods to a new setting.

Nursing home director of nursing leadership style and director of nursing-sensitive survey deficiencies

BACKGROUND

Nursing homes are becoming increasingly complex clinical environments because of rising resident acuity and expansion of postacute services within a context of historically poor quality performance. Discrete quality markers have been linked to director of nursing (DON) leadership behaviors. However, the impact of DON leadership across all measured areas of DON jurisdiction has not been tested using comprehensive domains of quality deficiencies.

PURPOSE

The aim of this study was to examine the effects of DON leadership style including behaviors that facilitate the exchange of information between diverse people on care quality domains through the lens of complexity science.

METHODOLOGY

Three thousand six hundred nine DONs completed leadership and intent-to-quit surveys. Quality markers that were deemed DON sensitive included all facility survey deficiencies in the domains of resident behaviors/facility practices, quality of life, nursing services, and quality of care. Logistic regression procedures estimated associations between variables.

FINDINGS

The odds of deficiencies for all DON sensitive survey domains were lower in facilities where DONs practiced complexity leadership including more staff input and shared decisional authority. DON quit intentions were aligned with higher odds of facility deficiencies across all domains.

PRACTICE IMPLICATIONS

Results supported the hypotheses that DONs using complexity leadership approaches by interacting more freely with staff, discussing resident issues, and sharing decision making produced better care outcomes from every DON sensitive metric assessed by Centers for Medicare and Medicaid Services. The mechanism linking poor quality with high DON quit intentions is an area for future research. Encouraging DON use of complexity leadership approaches has the potential to improve a broad swath of quality outcomes.

Association Between Therapy Intensity and Discharge Outcomes in Aged Medicare Skilled Nursing Facilities Admissions

OBJECTIVES

To determine the association between therapy intensity and discharge outcomes for aged Medicare skilled nursing facilities (SNFs) fee-for-service beneficiaries and to determine the association between therapy intensity and time to community discharge.

DESIGN

Retrospective observational design.

SETTING

SNFs.

PARTICIPANTS

Aged Medicare fee-for-service beneficiaries (N=311,338) in 3605 SNFs.

INTERVENTIONS

The total minutes of physical therapy, occupational therapy, and speech therapy per day were divided into intensity groups: high (≥60min); medium-high (45-<60min); medium-low (30-<45min); and low (<30min).

MAIN OUTCOME MEASURES

Four discharge outcomes-community, hospitalization, permanent placement, and death-were examined using a multivariate competing hazards model. For those associated with community discharge, a Poisson multivariate model was used to determine whether length of stay differed by intensity.

RESULTS

High intensity therapy was associated with more community discharges in comparison to the remaining intensity groups (hazard ratio, .84, .68, and .433 for medium-high, medium-low, and low intensity groups, respectively). More hospitalizations and deaths were found as therapy intensity decreased. Only high intensity therapy was associated with a 2-day shorter length of stay (incident rate ratio, .95).

CONCLUSIONS

High intensity therapy was associated with desirable discharge outcomes and may shorten SNF length of stay. Despite growing reimbursements to SNFs for rehabilitation services, there may be desirable benefits to beneficiaries who receive high intensity therapy.

A Communication Intervention to Reduce Resistiveness in Dementia Care: A Cluster Randomized Controlled Trial

Purpose of the Study

Nursing home (NH) residents with dementia exhibit challenging behaviors or resistiveness to care (RTC) that increase staff time, stress, and NH costs. RTC is linked to elderspeak communication. Communication training (Changing Talk [CHAT]) was provided to staff to reduce their use of elderspeak. We hypothesized that CHAT would improve staff communication and subsequently reduce RTC.

Methods

Thirteen NHs were randomized to intervention and control groups. Dyads (n = 42) including 29 staff and 27 persons with dementia were videorecorded during care before and/or after the intervention and at a 3-month follow-up. Videos were behaviorally coded for (a) staff communication (normal, elderspeak, or silence) and (b) resident behaviors (cooperative or RTC). Linear mixed modeling was used to evaluate training effects.

Results

On average, elderspeak declined from 34.6% (SD = 18.7) at baseline by 13.6% points (SD = 20.00) post intervention and 12.2% points (SD = 22.0) at 3-month follow-up. RTC declined from 35.7% (SD = 23.2) by 15.3% points (SD = 32.4) post intervention and 13.4% points (SD = 33.7) at 3 months. Linear mixed modeling determined that change in elderspeak was predicted by the intervention (b = -12.20, p = .028) and baseline elderspeak (b = -0.65, p < .001), whereas RTC change was predicted by elderspeak change (b = 0.43, p < .001); baseline RTC (b = -0.58, p < .001); and covariates.

Implications

A brief intervention can improve communication and reduce RTC, providing an effective nonpharmacological intervention to manage behavior and improve the quality of dementia care. No adverse events occurred.

Costs of a Staff Communication Intervention to Reduce Dementia Behaviors in Nursing Home Care

CONTEXT

Persons with Alzheimer's disease and other dementias experience behavioral symptoms that frequently result in nursing home (NH) placement. Managing behavioral symptoms in the NH increases staff time required to complete care, and adds to staff stress and turnover, with estimated cost increases of 30%. The Changing Talk to Reduce Resistivenes to Dementia Care (CHAT) study found that an intervention that improved staff communication by reducing elderspeak led to reduced behavioral symptoms of dementia or resistiveness to care (RTC).

OBJECTIVE

This analysis evaluates the cost-effectiveness of the CHAT intervention to reduce elderspeak communication by staff and RTC behaviors of NH residents with dementia.

DESIGN

Costs to provide the intervention were determined in eleven NHs that participated in the CHAT study during 2011-2013 using process-based costing. Each NH provided data on staff wages for the quarter before and for two quarters after the CHAT intervention. An incremental cost-effectiveness analysis was completed.

ANALYSIS

An average cost per participant was calculated based on the number and type of staff attending the CHAT training, plus materials and interventionist time. Regression estimates from the parent study then were applied to determine costs per unit reduction in staff elderspeak communication and resident RTC.

RESULTS

A one percentage point reduction in elderspeak costs $6.75 per staff member with average baseline elderspeak usage. Assuming that each staff cares for 2 residents with RTC, a one percentage point reduction in RTC costs $4.31 per resident using average baseline RTC.

CONCLUSIONS

Costs to reduce elderspeak and RTC depend on baseline levels of elderspeak and RTC, as well as the number of staff participating in CHAT training and numbers of residents with dementia-related behaviors. Overall, the 3-session CHAT training program is a cost-effective intervention for reducing RTC behaviors in dementia care.

Understaffing and registered nurses’ turnover: The moderating role of regular rest breaks

Current demographic and occupational changes call for new interventions to promote staff retention, especially in nursing where understaffing promotes turnover by increasing workload and strain. Based on previous research examining recovery at work, we investigated whether well-designed rest breaks can function as a resource that buffers adverse consequences of understaffing in nursing. We used a cross-sectional, multi-method study design and assessed understaffing of registered nurses, their regularity of rest breaks, and their annual turnover behaviour in 80 German geriatric nursing teams. As expected, understaffing positively predicted turnover only in work conditions with irregular rest breaks. Hence, implementing regularly scheduled rest breaks can be considered as an effective intervention for improving retention of nurses even in a situation of understaffing.

Facility Characteristics and Risk of Developing Pressure Ulcers in US Nursing Homes

This research studied 12,507 residents in 1174 nursing homes from the 2004 National Nursing Home Survey. A multinomial logistic regression model was used to predict risk-adjusted probabilities of pressure ulcers with 4 stages. A medical director or a director of nursing on board reduced the odds of ulcers. Facilities offering clusters of beds for rehabilitation and special care programs for hospice care or behavior problems reduced the odds of stage IV ulcers.

Voluntary and Involuntary Nursing Home Staff Turnover

The goal of this study was to identify nursing home characteristics that have differential associations to voluntary and involuntary turnover among formal caregivers (i.e., registered nurses, licensed practical nurses, and nurse aides). Primary data from 354 facilities from four states were merged with data from the 2004 Online Survey, Certification and Recording system. Multinomial logistic regression analyses were conducted to determine whether organizational characteristics were related to a greater probability of high or low levels of voluntary and involuntary turnover among formal caregivers. The analysis revealed that a higher ratio of nurses to beds, a smaller number of quality-of-care deficiencies, and a smaller proportion of residents using Medicaid were all associated with lower voluntary turnover but higher involuntary turnover. The findings indicate that controlling turnover is a complex process that may involve monitoring the organizational levels not only of voluntary separations but also of involuntary terminations.

Implementing guidelines in nursing homes: a systematic review

BACKGROUND

Research on guideline implementation strategies has mostly been conducted in settings which differ significantly from a nursing home setting and its transferability to the nursing home setting is therefore limited. The objective of this study was to systematically review the effects of interventions to improve the implementation of guidelines in nursing homes.

METHODS

A systematic literature search was conducted in the Cochrane Library, CINAHL, Embase, MEDLINE, DARE, HTA, CENTRAL, SveMed + and ISI Web of Science from their inception until August 2015. Reference screening and a citation search were performed. Studies were eligible if they evaluated any type of guideline implementation strategy in a nursing home setting. Eligible study designs were systematic reviews, randomised controlled trials, non-randomised controlled trials, controlled before-after studies and interrupted-time-series studies. The EPOC risk of bias tool was used to evaluate the risk of bias in the included studies. The overall quality of the evidence was rated using GRADE.

RESULTS

Five cluster-randomised controlled trials met the inclusion criteria, evaluating a total of six different multifaceted implementation strategies. One study reported a small statistically significant effect on professional practice, and two studies demonstrated small to moderate statistically significant effects on patient outcome. The overall quality of the evidence for all comparisons was low or very low using GRADE.

CONCLUSIONS

Little is known about how to improve the implementation of guidelines in nursing homes, and the evidence to support or discourage particular interventions is inconclusive. More implementation research is needed to ensure high quality of care in nursing homes.

PROTOCOL REGISTRATION

PROSPERO 2014: CRD42014007664.

The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes

Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.

The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes

Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.

Observational Evidence of For-Profit Delivery and Inferior Nursing Home Care: When Is There Enough Evidence for Policy Change?

Margaret McGregor and colleagues consider Bradford Hill's framework for examining causation in observational research for the association between nursing home care quality and for-profit ownership.

Nursing Home Staff Intentions for Learned Communication Skills: Knowledge to Practice

Staff education is critical to improving nursing home dementia care practice. However, a lag in translation to practice is a barrier to improving care. As part of a clinical trial testing effects of a communication intervention on behaviors of residents with dementia, participant-reported likelihood of using learned skills in practice was evaluated in relation to organizational and individual factors in 10 nursing homes. The authors hypothesized that organizational and individual factors would influence staff intention to use new skills in practice. Pre-and post-training comparisons confirmed that staff gained knowledge about communication effectiveness. Staff reported high likelihood for using skills in practice based on modified Duke Diffusion of Innovation (DOI) Scale scores. Care organization was correlated with total DOI scores (r = 0.82, p < 0.01). DOI subscales correlations to organizational and individual attitudes are reported. Evaluating quality improvement interventions in relation to translation to practice is essential in today's nursing home environment.

Correlates of service delivery and social environment in adult day service programs

The objectives of this study were to better describe adult day service (ADS) programs and determine how various structural and case mix characteristics of ADS were empirically associated with the services provided in and the social environments of adult day programs. All directors of ADS programs in Minnesota (United States) were contacted from 2011 to 2012 to complete a detailed online survey that collected information on ADS structure, client case mix, services and activities, and social environment (n = 83; 67.5% response rate). Several structural characteristics and case mix indicators (e.g., number of clients attending) were significantly associated (p < .05) with specific types of ADS service provision, such as health monitoring. Programs that were adequately staffed and perceived as pleasant appeared to also have a more vibrant social environment. The results suggest the potential need for bolstering staffing and enhancing the physical environment of ADS programs.

The Impact of State Nursing Home Staffing Standards on Nurse Staffing Levels

This study investigated the impact of state nursing home staffing standards on nurse staffing levels for the year 2011. Specifically, the study attempted to measure state staffing standards at facility level (i.e., nurse staffing levels that each individual nursing home must retain by its state staffing standards) and analyzed the policy impact. The study findings indicated that state staffing standards for the categories of registered nurse, licensed nurse, or total nurse are positively related to registered nurse, licensed nurse, or total nurse staffing levels, respectively. Nursing homes more actively responded to licensed staffing requirements than total staffing requirements. However, nursing homes did not increase their staffing levels as much as those required by state staffing standards. It is possibly because the quality-oriented inspection allows flexibility in nursing homes’ control of nurse staffing levels.

Comparing Person-Centered Communication Education in Long-Term Care Using Onsite and Online Formats

Educating nursing home (NH) staff to provide person-centered care is complicated by scheduling, costs, and other feasibility issues. The current study compared outcomes for an in-service program focused on person-centered communication provided in onsite and online formats. The Changing Talk program was provided onsite in seven NHs (n = 327 staff). The online program included eight NHs (n = 211 staff). Analysis of variance revealed an interaction between format type and pre-/post-test scores with improved recognition of person-centered communication in the onsite group only. Group program evaluations based on the modified Diffusion of Innovation in Long-Term Care Battery indicated no significant differences between training formats. Staff perception of the program was similar. Although statistically significant gains were noted in posttest scores indicating awareness of person-centered communication for the onsite group, gains were of limited clinical significance. Feasibility and effectiveness are important considerations for in-service education supporting NH culture change.

Hospital- and patient-related factors associated with differences in hospital antibiotic use: analysis of national surveillance results

Background

Surveillance data of antibiotic use are increasingly being used for benchmarking purposes, but there is a lack of studies dealing with how hospital- and patient-related factors affect antibiotic utilization in hospitals. Our objective was to identify factors that may contribute to differences in antibiotic use.

Methods

Based on pharmacy sales data (2006–2011), use of all antibiotics, all penicillins, and broad-spectrum antibiotics was analysed in 22 Health Enterprises (HEs). Antibiotic utilization was measured in World Health Organisation defined daily doses (DDDs) and hospital-adjusted (ha)DDDs, each related to the number of bed days (BDs) and the number of discharges. For each HE, all clinical specialties were included and the aggregated data at the HE level constituted the basis for the analyses. Fourteen variables potentially associated with the observed antibiotic use – extracted from validated national databases – were examined in 12 multiple linear regression models, with four different measurement units: DDD/100 BDs, DDD/100 discharges, haDDD/100 BDs and haDDD/100 discharges.

Results

Six variables were independently associated with antibiotic use, but with a variable pattern depending on the regression model. High levels of nurse staffing, high proportions of short (<2 days) and long (>10 days) hospital stays, infectious diseases being the main ICD-10 diagnostic codes, and surgical diagnosis-related groups were correlated with a high use of all antibiotics. University affiliated HEs had a lower level of antibiotic utilization than other institutions in eight of the 12 models, and carried a high explanatory strength. The use of broad-spectrum antibiotics correlated strongly with short and long hospital stays. There was a residual variance (30%–50% for all antibiotics; 60%–70% for broad-spectrum antibiotics) that our analysis did not explain.

Conclusions

The factors associated with hospital antibiotic use were mostly non-modifiable. By adjusting for these factors, it will be easier to evaluate and understand observed differences in antibiotic use between hospitals. Consequently, the inter-hospital differences can be more confidently acted upon. The residual variation is presumed to largely reflect prescriber-related factors.

[Impact of nurse, nurses' aid staffing and turnover rate on inpatient health outcomes in long term care hospitals]

PURPOSE

This study was conducted to explore the impact of registered nurse/nurses' aid (RN/NA) staffing and turnover rate on inpatient health outcomes in long term care hospitals.

METHODS

A secondary analysis was done of national data from the Health Insurance Review and Assessment Services including evaluation of long term care hospitals in October-December 2010 and hospital general characteristics in July-September 2010. Final analysis of data from 610 hospitals included RN/NA staffing, turnover rate of nursing staff and 5 patient health outcome indicators.

RESULTS

Finding showed that, when variables of organization and community level were controlled, patients per RN was a significant indicator of decline in ADL for patients with dementia, and new pressure ulcer development in the high risk group and worsening of pressure ulcers. Patients per NA was a significant indicator for new pressure ulcer development in the low risk group. Turnover rate was not significant for any variable.

CONCLUSION

To maintain and improve patient health outcomes of ADL and pressure ulcers, policies should be developed to increase the staffing level of RN. Studies are also needed to examine causal relation of NA staffing level, RN staffing level and patient health outcomes with consideration of the details of nursing practice.

Revisiting the relationship between nurse staffing and quality of care in nursing homes: an instrumental variables approach

This paper revisits the relationship between nurse staffing and quality of care in nursing homes using an instrumental variables approach. Most prior studies rely on cross-sectional evidence, which renders causal inference problematic and policy recommendations inappropriate. We exploit legislation changes regarding minimum staffing requirements in eight states between 2000 and 2001 as exogenous shocks to nurse staffing levels. We find that registered nurse staffing has a large and significant impact on quality of care, and that there is no evidence of a significant association between nurse aide staffing and quality of care. A comparison of the IV estimation to the OLS estimation of the first-difference model suggests that ignoring endogeneity would lead to an underestimation of how nurse staffing affects quality of care in nursing homes.

What does nurse turnover rate mean and what is the rate?

Registered nurse turnover is an important indicator of the nurse job market. Despite its wide use as a measure for health-care system analysis, there is a lack of consistency in the definition of turnover. Some definitions include any nurse leaving an organization; others may include involuntary and voluntary leaving. These inconsistent definitions also result in various turnover rates. The RN Work Project is a 10-year panel study of new nurses. Data were collected from the new nurses, rather than from a specific organization. About 17.5% of new nurses leave their first job within 1 year of starting their jobs. Consistent and accurate measurement of turnover is an important step in addressing organizational work environments and policies about the nursing workforce.

The role of organizational culture in retaining nursing workforce

PURPOSE OF THE STUDY

We examined how organizational culture in nursing homes affects staff turnover, because culture is a first step to creating satisfactory work environments.

DESIGN AND METHODS

Nursing home administrators were asked in 2009 to report on facility culture and staff turnover. We received responses from 419 of 1,056 administrators contacted. Respondents reported the strength of cultural values using scales from a Competing Values Framework and percent of staff leaving annually for Registered Nurse (RN), Licensed Practice Nurse (LPN), and nursing aide (NA) staff. We estimated negative binomial models predicting turnover. 

RESULTS

Turnover rates are lower than found in past but remain significantly higher among NAs than among RNs or LPNs. Facilities with stronger market values had increased turnover among RNs and LPNs, and among NAs when turnover was adjusted for facilities with few staff. Facilities emphasizing hierarchical internal processes had lower RN turnover. Group and developmental values focusing on staff and innovation only lowered LPN turnover. Finally, effects on NA turnover become insignificant when turnover was adjusted if voluntary turnover was reported.

IMPLICATIONS

Organizational culture had differential effects on the turnover of RN, LPN, and NA staff that should be addressed in developing culture-change strategies. More flexible organizational culture values were important for LPN staff only, whereas unexpectedly, greater emphasis on rigid internal rules helped facilities retain RNs. Facilities with a stronger focus on customer needs had higher turnover among all staff.

Applying the Advancing Excellence in America's Nursing Homes Circle of Success to improving and sustaining quality

Looking forward to the Quality Assurance Performance Improvement (QAPI) program to be implemented and required in 2014, and as nursing home staff provide care for residents with increasingly complex health issues, knowledge of how to implement quality improvement (QI) is imperative. The nursing home administrator and director of nursing (DON) provide overall leadership, but it is the primary responsibility of the DON and other registered nurse staff to implement and manage the day to day QI process. This article describes potential roles of nursing leaders and key components of a QI project using a pressure ulcer case study exemplar to illustrate a quality improvement process. The authors suggest specific methods that RN leaders can employ using the Advancing Excellence Campaign Circle of Success as an organizing framework along with evidence-based resources. Nursing home leaders could use this article as a guideline for implementing any clinical quality improvement process.

A cross-sectional study on association of work environment, coping style, and other risk factors with depression among caregivers in group homes in Japan

A cross-sectional study was conducted to explore the potential association between work environment and/or stress coping ability, and depressive status among caregivers working for "group homes (GHs)" in Japan. In January 2010, 438 out of 700 caregivers working at GHs in Sapporo City returned completed questionnaires to us. The questionnaires consisted of the Center of Epidemiological Scales-Depression, items about worker's attributions, Ozeki's coping scale, and so on. An analysis using a logistic regression model was used to find the associations adjusting for gender and age. Subjects who were 45 yr or older, had a spouse, had job training, a standard workload and scored high in emotion-oriented coping were significantly associated with a decreased risk of depression. Subjects who were less proud of their job, less willing to continue care for the frail elderly and had fewer acceptances by their supervisors or colleagues for consultation were significantly associated with an increased risk of depression. This study supports our hypothesis that there can be possible variables among individual factors, work environment and/or coping style for stress which may modulate a risk on the depressive status of caregivers.

Improving nursing home resident integrity by optimizing interpersonal communication skills in clinical staff

In this article the authors discuss the prevalence of resident abuse and reported violations of care deficiencies and resident maltreatment in nursing homes in the United States. The number of nursing homes in the United States that are cited with abuse violations has increased in recent years. While the authors recognize that treatments (both positive and negative) received by residents are sometimes related to factors other than staff's lack of knowledge and poor attitudes, their purpose in this analysis is to enhance resident integrity through the improvement of staff interpersonal communication skills. In doing so, innovative strategies and specific interpersonal communication theories are examined as educational methods to confront and resolve care deficiencies and elevate and enrich residents' integrity, satisfaction, and outcomes.

The relationship of California's Medicaid reimbursement system to nurse staffing levels

BACKGROUND

Policy initiatives at the Federal and state level are aimed at increasing staffing in nursing homes. These include direct staffing standards, public reporting, and financial incentives.

OBJECTIVE

To examine the impact of California's Medicaid reimbursement for nursing homes which includes incentives directed at staffing.

RESEARCH DESIGN

Two-stage limited-information maximum-likelihood regressions were used to model the relationship between staffing [registered nurses (RNs), licensed practical nurses, and certified nursing assistants hours per resident day] and the Medicaid payment rate, accounting for the specific structure of the payment system, endogeneity of payment and case-mix, and controlling for facility and market characteristics.

SAMPLE

A total of 927 California free-standing nursing homes in 2006.

MEASURES

The model included facility characteristics (case-mix, size, ownership, and chain affiliation), market competition and excess demand, labor supply and wages, unemployment, and female employment. The instrumental variable for Medicaid reimbursement was the peer group payment rate for 7 geographical market areas, and the instrumental variables for resident case-mix were the average county revenues for professional therapy establishments and the percent of county population aged 65 and over.

RESULTS

Consistent with the rate incentives and rational expectation behavior, expected nursing home reimbursement rates in 2008 were associated with increased RN staffing levels in 2006 but had no relationship with licensed practical nurse and certified nursing assistant staffing. The effect was estimated at 2 minutes per $10 increase in rate.

CONCLUSIONS

The incentives in the Medicaid system impacted only RN staffing suggesting the need to improve the state's rate setting methodology.