Nontraditional staffing models in long-term care

Real teams and their effect on the quality of care in nursing homes

BACKGROUND

Use of teams has shown to be an important factor for organizational performance. However, research has shown that a team has to meet certain criteria and operate in a certain way to realize the potential benefits of team organizing. There are few studies that have examined how teams operate in the nursing home sector and their effect on quality of care. This study investigates the relationship between teams that meet an academic definition of the team concept and quality of care in nursing homes.

METHODS

A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data. Five sources of data were utilized to test our research question: (1) self-report questionnaires to 444 employees, (2) interviews with 40 ward managers, (3) self-report questionnaires to 40 ward managers, (4) telephone interviews with 378 relatives, and (5) 900 hours of field observations. Use of teams in nursing home wards was assessed by field observations and by interviews with ward mangers. Quality of care was assessed by data from surveys and interviews with relatives and staff and through field observations. All data were aggregated to the ward level and two-level analyses were used to assess the relationships.

RESULTS

The multi-level analyses showed that teams - as operationalized in the present study - were significantly positively related to two out of the three quality of care indices when controlled for ward size, days of sick leave and care level. One significant interaction effect was found between teams and days of sick leave, implying that the effect of teams decreased with higher numbers of days of sick leave.

CONCLUSIONS

The results suggest that teams are related to higher levels of quality of care in nursing homes. However, the study shows that there is a substantial difference between real, functional teams that meet an academic definition of the concept and quasi teams, the latter having a significantly lower effect on quality of care. Hence, nursing home leaders, directors and ward leaders should be aware of the substantial differences betweens dysfunctional - or quasi - teams and real teams, and encourage the development of real functional teams to take advantage of the potential benefits of team organizing.

Effectiveness of staffing models in residential, subacute, extended aged care settings on patient and staff outcomes

BACKGROUND

A key concern for managers and nurse administrators of healthcare settings is staffing. Determining and maintaining an appropriate level and mix of staff is especially problematic for those working in the long-term aged-care sector, where resident needs are complex and recruitment and retention of staff is challenging.

OBJECTIVES

To identify which staffing models are associated with the best patient and staff outcomes.

SEARCH STRATEGY

We searched the Effective Practice and Organisation of Care (EPOC) Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness (DARE) in The Cochrane Library and the databases MEDLINE, EMBASE, Ageline, CINAHL, and Dissertation abstracts. We also handsearched the reference lists and bibliographies of all retrieved articles.

SELECTION CRITERIA

This review considered interrupted time series studies and studies with concurrent control designs of care staff or residents of residential or subacute or extended aged-care settings that evaluated the effectiveness of staffing models and skill mixes on resident and care staff outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors critically appraised all studies that were retrieved based on the screening of titles and abstracts according to the EPOC Group's data collection checklist.The same two review authors independently extracted and summarised details of eligible studies using the data abstraction form developed by EPOC.

MAIN RESULTS

We included two studies (one interrupted time series and one controlled before-and-after study); both evaluated a primary-care model compared with a either a team-nursing model or a usual-care model. The primary-care model was found to provide slightly better results than the comparator for some outcomes such as resident well-being or behaviour. While nursing staff favoured the primary-care model in one study, neither study found significant improvements in staff outcomes using the primary model compared with the comparator. One study evaluated the uptake of the primary-care model within their facilities and found incorporation of this model into their practice was limited.

AUTHORS' CONCLUSIONS

Apart from two small studies evaluating primary care, no evidence in the form of concurrently controlled trials could be identified. While these two studies generally favour the use of primary care, the research designs of both ITS and CBA studies are considered prone to bias, specifically selection and blinding of participants and assessors. Therefore, these studies should be regarded with caution and there is little clear evidence for the effective use of any specific model of care in residential aged care to benefit either residents or care staff. Research in this area is clearly needed.

Best practices in nursing homes. Clinical supervision, management, and human resource practices

Human resource practices including supervision and management are associated with organizational performance. Evidence supportive of such an association in nursing homes is found in the results of numerous research studies conducted during the past 17 years. In this article, best practices related to this topic have been culled from descriptive, explanatory, and intervention studies in a range of interdisciplinary research journals published between 1990 and 2007. Identified best practices include implementation of training programs on supervision and management for licensed nurses, certified nursing assistant job enrichment programs, implementation of consistent nursing assignments, and the use of electronic documentation. Organizational barriers and facilitators of these best practices are described.

Meeting the demographic challenges ahead: Toward culture change in an ageing New Zealand

There are several innovative service delivery models in the United States (US) relevant to long-term care policy development and implementation in New Zealand. An especially fruitful source of innovation has been the culture change movement, which originated in the US but has begun to spread to New Zealand and other OECD countries. The culture change philosophy requires that providers respond to the values, preferences, and needs of care recipients. It also requires devolving authority to direct care workers who know their clients best, in addition to transitioning from sterile 'clinical' settings to more homelike environments. New Zealand has a more favourable policy context for improving long-term care than the US. Thus, it is critical that it build upon these short term advantages to promote further dissemination of the culture change ethos, thereby placing caregivers in a better position to meet current care challenges, not to mention those posed by growth in the elderly population ahead.

A comprehensive systematic review of evidence on the structure, process, characteristics and composition of a nursing team that fosters a healthy work environment

OBJECTIVES

The overall aim of this comprehensive systematic review was to identify the best available evidence on the effect of team characteristics, processes, structure and composition within the context of collaborative practice among nursing teams that create a healthy work environment.

SEARCH STRATEGY

The search strategy sought to find both published and unpublished studies and papers written in the English language. An initial limited search of Medline and CINAHL databases was undertaken to identify optimal search terms. A second extensive search using all identified keywords and index terms was then undertaken.

METHODOLOGICAL QUALITY

Two independent reviewers assessed the methodological quality of retrieved papers using the corresponding checklist from the System for the Unified Management, Assessment and Review of Information (SUMARI) package.

RESULTS

The papers included in the review included nine experimental or quasi-experimental studies, 11 descriptive studies and four qualitative studies. A variety of different team structures such as interdisciplinary teams, primary nursing, team nursing, multidisciplinary models of care delivery and the use of a Partner in Patient Care model were investigated. Team characteristics should include accountability, commitment, enthusiasm and motivation. Social support within a team from a supervisor or colleague increased satisfaction levels of staff.

CONCLUSION

The results of the review lead to the development of a number of recommendations for practice that could assist with creating a health work environment.

Quality of Care in the Nursing Home: Effects of Staff Assignment and Work Shift

PURPOSE

The purpose of this study was to compare a variety of resident and staff outcomes across two types of staffing patterns, permanent and rotating assignment, and work shift. Although studies have examined these staffing patterns as part of multicomponent intervention packages, few studies have examined the isolated effects of staffing pattern by using an experimental design.

DESIGN AND METHODS

A between-groups comparison design was used to compare residents and certified nursing assistants (CNAs) from four nursing homes; two self-identified as using permanent assignment (PA) staffing and two as using rotating assignment (RA) staffing. Measures yielded data on verbal interaction among residents and staff, resident disruptive behavior, and specific aspects of resident-staff behavior during care routines. Other assessments included resident personal appearance and hygiene, expressed affect, and CNAs' job satisfaction, burnout, absenteeism, and turnover rates. A treatment fidelity check was conducted to confirm PA and RA staffing patterns.

RESULTS

Staffing patterns were significantly different between self-identified PA and RA nursing homes. Residents in PA nursing homes and on morning shifts received significantly higher ratings of personal appearance and hygiene. Rates of expressed sadness and interest among residents differed by staffing patterns and shift. However, these differences do not appear to be clinically significant. Although absenteeism was higher in PA nursing homes, these CNAs reported greater job satisfaction than CNAs from RA nursing homes. As expected, evening shifts across nursing homes had significantly higher turnover rates and significantly more resident disruptive behavior.

IMPLICATIONS

Quality-of-care outcomes were similar among the two types of nursing homes, despite significantly different staffing patterns. Though staff permanency rates in PA nursing homes (50%) were twice that of RA nursing homes (26%), more research is needed to determine feasibility of higher rates of staff permanency (i.e., > 50%) and effects on resident and CNA outcomes.

Enhancing relationships between care providers and residents in long-term care. Designing a model of care

Research in three different areas was examined and several conclusions can be drawn. Continuity of care provider is critical to understanding the resident and to developing relationships with the resident over time (Patchner, 1987; Teresi et al., 1993a). The teaching of interactional skills is not enough; the care provider must be engaged in some way, such as learning about the person through life stories (Best, 1998; Caris-Verhallen et al., 2000; Coker et al., 1998; Heliker, 1999; McCallion et al., 1999; Pietrukowicz & Johnson, 1991; Williams & Tappen, 1999). If care providers are called to enhance relationships with residents, they too must be supported in their work environments (Hallberg & Norberg, 1993; Montegar et al., 1977; Kovach & Krejci, 1998). Finally, research confirmed positive secondary resident and care provider outcomes can be achieved following the development of holding relationships. Overall, preliminary empirical support for the capacities of the care provider--reliability, empathy, continuity--and for the requirement for support were established from a review of the literature. However, no intervention studies were found that incorporated the complete set of theoretical variables. Testing the combined influence of these variables, as conceptualized by Winnicott's (1970) theory of relationships, and the manner in which they affect the holding relationship for residents, and subsequently secondary care provider and resident outcomes, is essential to assess the usefulness of this theory to relationship building in LTC. Caregiving relationships involve all kinds of social interaction during the course of which the patient's sense of self-worth can either be enhanced or thwarted (Agich, 1990). Therefore, a milieu should be developed to accentuate care provider-resident relationships and lead to a systematic and encompassing framework of positive expectations on the part of all nursing personnel involved. A model of care focusing on relationships may be one means to this end.