Nursing Indicators of Quality in Nursing Homes

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.

Exploring perceptions of health caregivers on the causes of caregivers' occupational burnout in institutes of children with cerebral palsy: A qualitative study

BACKGROUND

Providing care for children with cerebral palsy (CP) is hard, energy-consuming, and long-term. Consequently, occupational burnout is highly probable for caregivers.

OBJECTIVE

This study aimed to explore the perception of health caregivers regarding the causes of caregivers' occupational burnout in institutes of children with CP.

METHODS

This qualitative study was conducted using content analysis methodology during an eight-month period in 2016. Nine caregivers, two managers, and one physiotherapist participated in the study. Purposive sampling method was used to select participants. In depth, semi-structure interviews were used to gather the data. All interviews were conducted at their workplace, in Tehran, Iran. The interviews were recorded, transcribed verbatim, and overviewed. Constant comparative analyses were used to analyze the interviews.

RESULTS

The results were categorized into three main categories and nine sub-categories. The main categories were as follows: care-related stress, nature of caring occupation, and organizational demands and resources.

CONCLUSION

Results of this study showed that several factors are involved in creating burnout among caregivers. The exploration of these factors may help us in designing appropriate interventions for caregivers to correctly implement caring activities so that they less suffer from care-related pressures and also become able to allocate some time for their own activities of interest and for recreational, social, and family activities.

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.

Effect of nursing home characteristics on residents' quality of life: a systematic review

The association between nursing home (NH) characteristics and residents' quality of life (QOL) has not been systematically reviewed. This study synthesizes published evidence about the association between NH ownership, affiliation, location, chain membership, percentage of private rooms, facility size, and staffing with residents' QOL. We searched Medline, Web of Science, CINAHL, and Scirus for primary studies published between 1960 and March 31, 2012. We critically appraised risk of bias according to study design, QOL measurements, and adjustment for residents' characteristics. We analyzed the statistical and clinical significance, direction and magnitude of the association. From 1117 citations retrieved, we found one longitudinal quasi-experimental and 10 cross-sectional eligible studies. Variability in the NH characteristics reported and QOL measurements precluded meta-analysis. Studies with low and medium risk of bias (ROB) suggested that nonprofit NHs resulted in better QOL for residents. The low ROB study indicated that in certain QOL domains, rural facilities and facilities with a higher percentage of private rooms were associated with better self-reported resident QOL. All low and medium ROB studies found that RN, LVN/LPN and total nursing staff had no significant relationship with QOL. One longitudinal quasi-experimental study indicated that the Green House with individualized care had better QOL than conventional NHs. The available evidence does not permit strong conclusions about the association between NH characteristics and residents' QOL. The evidence does, however, raise questions about whether NH structure alone can improve residents' QOL and how residents' QOL should be measured and improved.

Exploring Factors Associated With Turnover Among Registered Nurse (RN) Supervisors in Nursing Homes

Because most turnover studies focus on certified nursing assistants (CNAs), licensed vocational nurses (LVNs), and administrators, little is known about registered nurses’ (RNs) higher turnover. This study builds on the current body of knowledge about turnover among RN supervisors in nursing homes. The article discusses a survey of RN nurse supervisors administered in more than 1,000 nursing homes that was merged with the 2003 Texas Medicaid cost report and the area resource file. Two 2-stage models are developed to predict RN turnover rates. RNs’ intent to leave predicts RN turnover through job satisfaction, perceived empowerment, and education level. High LVN and CNA turnover and high Medicare census are associated with higher turnover. Implications are that participation in management decisions and perceived wage competitiveness are an important determinant of RN retention in nursing homes. Future research should focus why RN supervisors with higher levels of education leave nursing homes.

Improving the oral health of older people in long-term residential care: a review of the literature

Background.  Unrefutable evidence now links poor oral health with the development of preventable systemic illnesses and debilitating conditions that threaten quality of life and life itself. This is especially significant for an increasing older population who are dependent on others for care. Aims and objectives.  The majority of studies analysing the oral health of older dependent people in long-term residential care have been undertaken by dental professionals. This critical literature review examines the issue from a nursing perspective because nursing care providers have a fundamental role in daily oral health provision for dependent residents. Conclusions.  Multiple barriers were found to negatively impact on daily oral healthcare provision, including lack of care provider education, oral health values, availability of resources, implementation of supportive policies, documentation and oral health assessment tools. Relevance to clinical practice.  The nursing profession, at all levels, must become pro-active in removing financial, political and workforce barriers that impact negatively on oral health outcomes. A multi-faceted approach is required to address these barriers, including development and implementation of oral health education programmes, assessment screening tools, care plans, documentation, supply of oral hygiene aids and the appointment of oral care 'champions'.

[Use of Internet resources in nursing: a review]

Resources of Internet system are widely popularized in most of all human activities in the society. This paper aims to identify and to describe major modalities of Internet utilization in nursing areas of Education, Care, and Research. This is a bibliographic review which data source was MEDLINE database, using pertinent descriptors for the focused areas. From referred publications, it was selected 63 articles. Major utilization in Education area is the development of applications to promote distance education; in Patient Education area is the development of applications to make health information available; in Care area are the applications to make care protocols available to promote evidence-based practice, and in Research area is online data collection. It was concluded that nursing is using Internet resources in a satisfactory way, and it has contributed for the profession evolution.

Mental Health Care Deficiency Citations in Nursing Homes and Caregiver Staffing

In this paper, we examine the association between caregiver staffing levels and mental health outcomes in approximately 17,000 U.S. nursing homes. As outcomes, we focus on deficiency citations available in the Center for Medicare and Medicaid Services' Online Survey, Certification, And Recording data. We examine nurse aide, licensed practical nurse, registered nurse, and mental health provider staffing. Our results show that the level of nursing staff matter with respect to mental health outcomes. Whereas greater RN staffing was associated with a lower likelihood of being cited for deficiencies in mental health care, greater LPN and NA staffing were associated with a higher likelihood. We found no association between mental health provider staffing levels and mental health outcomes.

Discharge planning, nursing home placement, and the Internet

BACKGROUND

Effective discharge planning and well-coordinated case management related to nursing home (NH) placement are key services in acute-care hospitals.

OBJECTIVES

(1) identify the individuals and important factors involved in the discharge planning process; (2) describe the types/sources of information used by discharge planners to recommend specific nursing homes for patients and families; and (3) determine which methods are used to evaluate the quality of US nursing homes (NHs).

METHODS

Descriptive study, with a convenience sample of 41 discharge planners and case managers from California acute-care hospitals.

RESULTS

This study found that patients, families, friends, and physicians are all involved in the discharge planning process along with discharge planners and/or case managers. Discharge planners/case managers were generally concerned about NH bed availability, geographic location, and financial considerations. Although the discharge planners and case managers were able to articulate important indicators of quality in NHs, such information was not routinely considered during discharge planning activities.

CONCLUSIONS

Discharge planners and case managers need to play a more central role in the decision-making process related to the selection of a NH, especially because decisions are time-limited and can benefit from a well-planned discharge planning program that uses a variety of data on quality and costs. The widespread use of Internet-based information sources can be expanded to aid this process.

Physician and nurse staffing in nursing homes: The role and limitations of the Online Survey Certification and Reporting (OSCAR) system

OBJECTIVES

To assess nursing home staffing data reported in the Online Survey Certification and Reporting (OSCAR) system database for research and policy.

DESIGN

Comparisons were made between OSCAR and a concurrent research survey of staffing data collected for the same facilities, using inter-rater agreement and correlation analyses.

SETTING

Freestanding nursing homes from New York State (NYS) in 1997 (N = 327).

MEASUREMENTS

Selected staffing variables were defined in comparable terms in both OSCAR and the NYS survey.

RESULTS

The two data sources were in substantial agreement on the reported availability of a full-time physician (other than medical director) and of a physician assistant or nurse practitioner (Kappa >0.7), and they correlated well in the full-time equivalent (FTE) number of such staff (Spearman correlation >0.6). The correlation was 0.8 for FTE registered nurses (RNs), 0.7 for licensed practical nurses (LPNs), and 0.8 for certified nurse aides (CNAs). In terms of average nurse hours per patient day, separately for RNs, LPNs, CNAs, and all combined, the correlation was relatively weak (between 0.3 and 0.6). Overall staffing levels tended to be lower in OSCAR than in NYS.

CONCLUSION

The OSCAR data are useful for exploring relationships between staffing and various quality of care outcomes, but may not be accurate enough on a case-specific basis, or to determine policy regarding minimal staffing levels using average nurse hours per patient day measures. More systematic and timely efforts are needed to refine the OSCAR content and survey methodology to document nursing home staffing information.