Psychological and Structural Burdens and Nursing Home Administrator Turnover Intentions During the COVID-19 Pandemic

The COVID-19 pandemic created challenges for U. S. nursing home administrators (NHA) and staff. This study explored organizational and psychological factors associated with NHA stress, dissatisfaction, and turnover intent (TI) during the third year of the pandemic. Results from a nationwide, cross-sectional survey of 1139 NHAs were merged with Centers for Medicare and Medicaid Services nursing home survey deficiency, staffing, complaint, and other operations data. A hierarchical, generalized estimating equations model with ordered logit link found that NHAs with higher COVID stress (AOR = 1.65, 95% CI = 1.22, 2.23), higher use of agency/contract staff (AOR = 1.50, 95% CI = 1.08.2.09) and higher role conflict were more likely to indicate TI. NHAs with higher job satisfaction in workload, work content, and rewards were less likely to hold TI. Industry leaders should create strategies to reduce NHA's job stress and role conflicts and provide opportunities for improving staff recruitment and retention, reducing reliance on agency staffing.

Nurse Practitioner Employment in Relation to Nursing Staff Turnover and Resident Care Outcomes in US Nursing Homes

OBJECTIVES

A growing number of nurse practitioners (NPs) are employed in nursing homes (NHs) through various NP staffing mechanisms. The purpose of this study was to examine if having NH-employed NPs was associated with nursing staff turnover and resident care outcomes measured as hospital utilization, infection control citations, and substantiated complaints in NHs in 2021-2022.

DESIGN

A cross-sectional, retrospective study.

SETTING AND PARTICIPANTS

A total of 13,966 NHs from payroll-based journal (PBJ) and claim-based quality measures published by the Centers for Medicare and Medicaid Services in 2021-2022.

METHODS

Facilities were identified as having NH-employed NPs if at least 1 employed NP with paid working hours ≥10 per week was reported through the PBJ. We examined if having NH-employed NPs was associated with nursing staff turnover rates, unplanned hospital utilization, infection control citations, and substantiated complaints using doubly robust estimation that combined inverse probability weight representing the NH's likelihood of employing NPs and outcome regression.

RESULTS

Approximately, 2.8% of NHs had employed NPs. Facilities with NH-employed NPs tended to be larger, hospital affiliated, and not for profit with greater medical and nursing staff availability. In addition, a significantly higher proportion of facilities with NH-employed NPs were in metropolitan areas or states with full NP practice independence. We found that facilities with NH-employed NPs had significantly lower registered nurse (adjusted β, -5.40; 95% CI, -9.50 to -1.30) and certified nursing assistant turnover rates (adjusted β, -3.35; 95% CI, -6.29 to -0.40). Facilities with NH-employed NPs also had significantly fewer long-stay resident hospitalizations, infection control citations, and substantial complaints compared with those with no NH-employed NPs.

CONCLUSIONS AND IMPLICATIONS

This study highlights the value of NH-employed NPs to improve registered nurse and certified nursing assistant staff retention and NH resident outcomes. NH stakeholders and policymakers may consider various strategies to incentivize NP employment in NHs such as removing regulatory barriers to NP practice.

ASSISTED LIVING ADMINISTRATORS’ JOB SATISFACTION, WORK STRESSORS, AND INTENT TO LEAVE DURING THE COVID-19 PANDEMIC

This study examines how job satisfaction in six sub-scales and selected stressors and demographic covariates influenced assisted living administrators’ (ALF) intentions to quit during the COVID-19 pandemic. Quantitative and qualitative data were collected from 103 ALF administrators as part of a national study of long-term care administrators’ intent to quit during the COVID-19 pandemic funded by the Foundation of the National Association of Long-Term Care Administrator Boards in Washington, DC. Descriptive statistics were collected for the sample, and correlations between variables were examined, as well as responses from 3 open-ended questions that were coded for analysis. Although generally satisfied, roughly 41 percent of ALF administrators reported that they were intending to quit. Qualitative data suggested that job satisfaction was influenced by a more nuanced interpretation of job characteristics and work environment intrinsic factors such as adequacy of staffing and resources, changing regulations during the COVID-19 pandemic, and external supports such as family and friends. Given the limited research on the impact of the COVID-19 pandemic on assisted living communities and their administrators, the results of this study can help to inform policies and strategies for providing support for this segment of long-term services and its workforce during widespread disasters.

When Advocates are Forced to go Virtual: The Long-Term Care Ombudsman Response to COVID 19

Animal-assisted activities (AAA) and therapy standards of practice have been published to protect the well-being of animals, animal handlers, and the special populations of patients that benefit from this mode of treatment. Inconsistencies among practice standards with concerns surrounding the topics of dog welfare, human well-being, and zoonotic transmission have been reported. The purpose of this qualitative research study was to review published AAA and therapy standards with older adult populations for best practices, conduct focus group sessions with caregivers from long-term care facilities that allow therapy dog visitation, and synthesize findings into an AAA checklist to be used by long-term care facility decision-makers when interviewing or bringing in therapy dog teams. Comparative analyses utilizing a systematic and sequential approach was used to analyze the data from the focus group sessions. Due to the COVID-19 pandemic, only two focus group sessions at one long-term care facility were conducted resulting in a total of 15 caregivers. Four themes emerged from the data: promotes positive mood, essential resident screenings, caregiver roles, and memory aides. Relevant themes and AAA and therapy standards and guidelines were then combined in the development of the AAA/Therapy Dog Checklist. Administrators may find having a user-friendly AAA/therapy dog checklist a useful tool that can be used when interviewing therapy dog teams to ensure future dog therapy experiences will be positive and safe. The safety and well-being of residents in long-term care facilities and animals are essential to promote positive health outcomes for both populations.

Nursing Home Administrator's Job Satisfaction, Work Stressors, and Intent to Leave

This study examines how job satisfaction in six subscales and select stressors and demographic covariates influence nursing home administrator's (NHA) intentions to quit. Quantitative and qualitative data were collected from 311 NHAs in five states. Adjusted odds ratios and 95% confidence intervals for the ordered logistic regression models indicated that NHAs with satisfying work demands, rewards, and coworkers, and who experienced less role conflict and had fewer prior nursing home jobs had lower turnover intentions. Although generally satisfied, roughly 24% reported intending to quit. Surprisingly, NHAs reporting higher job skills were more likely to consider leaving, suggesting that talented NHAs may choose career advancement eased by stigma-free job-hopping in an industry with high mobility norms. Qualitative data suggested that job satisfaction/dissatisfaction was influenced by a more nuanced interpretation of satisfying and more taxing job facets and quitting triggers, including themes such as helping residents and struggling with regulations.

NURSING HOME ADMINISTRATOR STRESS, SATISFACTION, AND INTENTIONS TO LEAVE

Previous studies reported that high Nursing Home Administrator (NHA) turnover correlates with low staff morale and poorer care outcomes. The purpose of this study was to assess how NHA job satisfaction (JS) (in five subscales: job content, coworkers, work demands, work load, work skills, and rewards) interacts with role conflict and ambiguity, autonomy, work conflict, and influence and to estimate the odds of having NHA’s intent to quit by degree of job satisfaction. A total 208 responses were collected from the online survey in 2017 among NHAs currently working in nursing homes in 5 states. We analyzed the data using descriptive statistics and ordinal logistic regression models. The findings suggested that NHAs were generally satisfied in all JS subscales and expressed moderately high levels of autonomy, neutral levels of work conflict, role conflict and role ambiguity. NHAs with good coworker relations (adjusted odds ratio [AOR]=0.67), fair job demands (AOR=0.68) and rewards (A0R=0.8), were less likely to harbor quitting intents. Interestingly, NHAs reporting higher job skills were more likely to consider leaving nursing homes (AOR=1.46). Overall, study findings are consistent with previous JS research with the exception that higher perceived skill efficacy was found to be associated with greater likelihood of quitting in the near future. This suggests perhaps that more highly skilled NHAs may now have less tolerance for work discomfort. These findings are presented in the context of earlier studies on NHA turnover as well as likely implications of changing market conditions.

Factors Effecting Volunteer Ombudsman Effort and Service Duration: Comparing Active and Resigned Volunteers

Volunteers are key to successful ombudsmen programs. Motivating them and keeping them is difficult. The principal goal of this article is to compare active and resigned volunteer ombudsman perceptions (along with select demographic influences) of factors that either encouraged or discouraged their work. The authors find that former ombudsmen felt more role ambiguity, greater nursing facility resistance, higher boredom, and desired better supervision than active volunteer ombudsmen. They also served less time in significantly smaller facilities. Both active and resigned volunteers perceived relatively high role conflict. Implications regarding strategies to improve volunteer ombudsman work effort and retention are discussed.

State long-term care ombudsmen's perceptions of their program's disaster preparedness roles and readiness

A telephone survey of 43 state long-term care ombudsmen (LTCO) assessed their familiarity with relevant long-term care disaster resources, their provision of disaster aids and training to staff, and their perceived preparedness to lead their programs during public crises. Thirty-four directors (78%) reported being fairly well to fully prepared to support their local programs during public emergencies. However, ANOVAs showed that the 27 disaster experienced ombudsmen felt no better prepared to help their local paid and volunteer staff deal with public emergencies than disaster inexperienced ombudsmen. Those directly involved with emergency planners felt better prepared to help their substate staff to know where to start helping residents during a public crisis than ombudsmen who had no involvement with disaster planners. Familiarity with the Centers for Medicare and Medicaid Services Emergency Planning Checklist for LTC Ombudsmen (2007) was strongly associated with the ombudsmen's familiarity with emergency resources and regulations.

Pediatric disaster simulation in graduate and undergraduate nursing education

A university partnered with community agencies to include children and parents in a mass casualty full scale exercise on an academic campus. Nursing undergraduate students provided care to students in a multidisciplinary environment that involved hundreds of victims and health care personnel. One graduate nursing student worked with a youth theater group to provide disaster preparedness education to the children, culminating in their participation in the disaster exercise. Parents reported that the exercise was positive, that they would participate again, and that their children enjoyed the experience.

Current practice and policy realities revisited: undertrained nursing home social workers in the U.S

Despite a nearly 20-year-old legislation to strengthen social work (SW) coverage within nursing homes and decades of literature exploring the need for SW training, untrained and undertrained social workers dominate American nursing homes. Many persons who call themselves social workers are not educated as such, but nevertheless, must work in complex, conflict-ridden nursing homes without assessment and advocacy skills essential to address the symptoms and to fully respond to subjugated residents' needs. The call for more qualified social workers to be employed in nursing homes is a recognition that the residents' psychosocial needs are not being met. We examine how inconsistent national requirements, inadequate professional educational preparation, and work overload are all symptoms of a general societal unwillingness to recognize residents' needs. The authors utilize a morphogenic systems perspective to describe the open interaction between all disciplines, which can be unduly strained without properly trained workers. The social work literature is reviewed with a renewed interest in addressing the problem profession-wide.

Nursing home complaints: who's complaining and what's gender got to do with it?

Long Term Care Ombudsman Complaint data from one state's 261 nursing homes are examined in the study. We assessed differences between male and female groups, including chiefly residents, but also ombudsmen, the residents' relatives or friends, administrators, legal representatives, and others regarding types and rates of complaints as reported in the Administration on Aging (AoA) major categories of: Resident Care, Resident Rights, Administration, Quality of Life, and Complaints Not Against Facility. Proportionately, male residents lodged more complaints than females. Further, males complained more than females about Resident Rights violations and filed more Complaints Not Against Facility. Females lodged significantly more complaints about Care, Quality of Life and Administration.Thus, males were more likely to report technical, impersonal, and legalistic issues, than females, who were more likely to express concerns about personal care and socioemotional-environmental issues. Results yielded further evidence of gender differences in the patterns of resident complaints. Nursing home social workers are highlighted as agents in changing embedded stereotypes about residents and complaints.

Factors important to success in the volunteer long-term care ombudsman role

This study found that the satisfaction of one state's largely older volunteers' altruistic, affiliation, and self-improvement motives corresponded to increased organizational loyalty and better performance across several dimensions. Younger volunteers served for shorter periods and were more highly motivated by the "self-improvement" need. Altruism and organizational loyalty emerged as particularly important motivations.

The causes and consequences of conflict and violence in nursing homes: working toward a collaborative work culture

Interpersonal conflict, often spiraling to violence and abuse, is one of the most daunting challenges facing nursing home administrators and their departmental heads. Mounting evidence documents how they spend an inordinate amount of time dealing with angry families, adversarial ombudsmen, regulators, and other hostile parties as well as handling the aftermath of the ubiquitous conflict between the residents and their direct caregivers. All this is in addition to coping with the normal interdepartmental and line staff forms of conflict that typify any organization. This paper details the special dynamics that accelerate dysfunctional conflict in nursing homes and presents strategies, tactics, and style recommendations that will help nursing home leaders build more collaborative work cultures to minimize the effects of dysfunctional conflict.

The Causes and Consequences of Conflict and Violence in Nursing Homes

Interpersonal conflict, often spiraling to violence and abuse, is one of the most daunting challenges facing nursing home administrators and their departmental heads. Mounting evidence documents how they spend an inordinate amount of time dealing with angry families, adversarial ombudsmen, regulators, and other hostile parties as well as handling the aftermath of the ubiquitous conflict between the residents and their direct caregivers. All this is in addition to coping with the normal interdepartmental and line staff forms of conflict that typify any organization. This paper details the special dynamics that accelerate dysfunctional conflict in nursing homes and presents strategies, tactics, and style recommendations that will help nursing home leaders build more collaborative work cultures to minimize the effects of dysfunctional conflict.

National standards for the long-term care ombudsman program and a tool to assess compliance: the Huber Badrak Borders Scales

PURPOSE

We propose national standards previously recommended for the Long-Term Care Ombudsman Program by an Institute of Medicine program evaluation committee, and introduce a tool to measure the compliance of local ombudsman programs to those standards: the Huber Badrak Borders Scales.

METHODS

The best practices for ombudsman programs detailed in the committee's report were adapted to 43 Likert-type scales that were then averaged into 10 infrastructure component scales: (a) program structure, (b) qualifications of local ombudsmen, (c) legal authority, (d) financial resources, (e) management information systems, (f) legal resources, (g) human resources, (h) resident advocacy services, (i) systemic advocacy, and (j) educational services. The scales were pilot-tested in 1996 and 1999 with Kentucky ombudsmen.

RESULTS

The means of 9 of these 10 scales were higher in 1999 than in 1996, suggesting that local ombudsman programs were more in compliance with the proposed standards in 1999 than three years earlier.

IMPLICATIONS

The development process consisted of 10 adopt-test-revise-retest steps that can be replicated by other types of programs to develop program compliance tools.

Data from long-term care ombudsman programs in six states: the implications of collecting resident demographics

PURPOSE

This article focuses on why it is important for longterm care ombudsmen to collect resident demographics.

DESIGN AND METHODS

The authors analyzed a cross-sectional, 6-state database to show the importance of ombudsman programs' collecting demographic information about the residents of long-term care facilities whom they serve. To demonstrate the importance of collecting demographic data about residents, the authors examined the relationships between race, gender, and types of complaints lodged, verified, and fully resolved.

RESULTS

A higher percentage of complaints lodged on behalf of racial minorities was verified, yet a lower percentage was fully resolved.

IMPLICATIONS

Ombudsman databases are a potential resource for identifying residents' characteristics that increase their vulnerability in long-term care settings.

The relationship between volunteer long-term care ombudsmen and regulatory nursing home actions

This study assesses the relationship between the presence of Oregon volunteer long-term care ombudsmen and externally handled abuse complaints, survey reports, and regulatory sanctions. In 1987, new amendments to the Older Americans Act mandated long-term care ombudsmen access to nursing homes. No studies have systematically examined the relationship between these empowered ombudsmen programs and regulatory abuse investigations, survey findings, or sanction activities. Contrary to pre-1987 studies, this research found that the presence of ombudsmen was related to increased abuse reporting and abuse complaint substantiations, more survey deficiencies, and higher sanction activity.