Resident satisfaction and its components in residential aged care

PURPOSE: The purpose of this study was to assess the direction and magnitude of the effects among the components of resident satisfaction in residential aged care and to examine if the relationships among satisfaction components vary according to facility type (i.e., nursing home and hostel). Briefly, a hostel is a low-care facility in which residents are more independent and receive personal but not nursing care. DESIGN AND METHODS: A cross-sectional survey design was adopted to collect the required information, and a stratified random sampling approach was used to select facilities. Structural equation modeling was used to examine relationships among satisfaction components in a sample of 394 nursing home and 752 hostel residents. RESULTS: The results indicate that satisfaction with staff care has a moderate and positive effect on all other aspects of resident satisfaction. The relationships among satisfaction components are different for nursing home and hostel residents. IMPLICATIONS: The findings lead to an improved understanding of the interrelationship among resident satisfaction components, which has important implications for improving quality outcomes (e.g., resident satisfaction) through appropriate intervention (e.g., enhancing staff care).     

Retention and survival of hostel residents – a 12 year study

Abstract Background: The admission of a proportion of disabled people to hostels is inevitably followed by their transfer to nursing homes. Our hypothesis was that such admissions are justified in terms of quality of life and the cost to the community, notwithstanding the necessity of subsequent transfer. Aims: To test this hypothesis by measuring the retention and survival times of residents in hostel and in nursing home; to consider the relevance of these factors to the future policy of the two institutions. Methods: A retrospective study was made of 159 residents admitted over a period of 12 years to a hostel with 32 places. Times spent in the hostel and in the nursing home were recorded. Probabilities of survival in hostel and in nursing home were calculated according to the Kaplan-Meier method. Comparison with the expected survival of a matched cohort of the total population was determined. Estimation was made, using the SAS software package, of the likely number of places needed in nursing homes for residents following transfer. Results: Although the majority of hostel residents eventually needed nursing home care, a worthwhile proportion of their total institutional time (approximately two-thirds) was spent in the hostel. Ongoing support from the personnel in a geriatric service is likely to increase retention time in the hostel. Because of the ultimate outcome for the majority of residents, planning for hostel care should include consideration of places needed in nursing homes.     

A Special Dementia Unit (Hostel): Review of the First Eleven Years Operation

The aim of this review was to study the outcome of residents in a Special Dementia Unit (SDU) in the form of a hostel for 36 people during the first eleven years of operation. The participants were one hundred and seventy one residents admitted for permanent care during that period. The median length of stay in the hostel was 2.3 years. By the end of the period 113 residents (83 percent of those who had completed their time in the hostel) had been transferred to nursing homes. The average survival time after admission to the hostel was 4.7 years. In order to accommodate those who had been transferred from the SDU about the same number of hostel places were needed in nursing homes. We concluded that admission to an SDU hostel for selected people with dementia is more appropriate and less costly than direct admission to a nursing home, notwithstanding the need for subsequent nursing care for the majority. Adequate subsidy should be provided by the Commonwealth Government so that voluntary associations are encouraged to set up SDU hostels for this purpose. Nursing homes should be run in association with these hostels.     

The Use of Nursing Homes and Hostels for Respite Care

Objective: To examine the use of respite care in nursing homes and hostels and the destinations of respite residents on completion of their respite stay. Method: Administrative by-product data on admissions and separations from nursing homes and hostels are analysed to show the length and pattern of stay of respite residents. Results: The data show that utilisation rate of approved respite beds is relatively low: 69% for hostels in 1994–95 and 50% for nursing homes. This is in spite of government subsidies available for respite care. Many respite residents become permanent residents. Thirty percent of hostel residents in 1992–93 and 42% of nursing home residents in 1993–94 became permanent residents after their first respite admission. Conclusion: The transfer from respite to permanency may be caused by changes in personal circumstances of respite residents and their carers after respite admission. But it may also indicate an inappropriate use of respite beds. The reasons behind the considerable proportion of residents moving to permanent care and the low level of use of respite beds are worth further study.     

Nursing home quality, cost, staffing, and staff mix

PURPOSE:The purpose of this study was to describe the processes of care, organizational attributes, cost of care, staffing level, and staff mix in a sample of Missouri homes with good, average, and poor resident outcomes. DESIGN AND METHODS:A three-group exploratory study design was used, with 92 nursing homes randomly selected from all nursing homes in Missouri and classified into resident outcome groups. Resident outcomes were measured by use of quality indicators derived from nursing home Minimum Data Set resident assessment data. Cost and staffing information were derived from Medicaid cost reports. Participant observation methods were used to describe the care delivery processes. RESULTS:In facilities with good resident outcomes, there are basics of care and processes surrounding each that staff consistently do: helping residents with ambulation, nutrition and hydration, and toileting and bowel regularity; preventing skin breakdown; and managing pain. The analysis revealed necessary organizational attributes that must be in place in order for those basics of care to be accomplished: consistent nursing and administrative leadership, the use of team and group processes, and an active quality improvement program. The only facility characteristic across the outcome groups that was significantly different was the number of licensed beds, with smaller facilities having better outcomes. No significant differences in costs, staffing, or staff mix were detected across the groups. A trend in higher total costs of 13.58 dollars per resident per day was detected in the poor-outcome group compared with the good-outcome group. IMPLICATIONS:For nursing homes to achieve good resident outcomes, they must have leadership that is willing to embrace quality improvement and group process and see that the basics of care delivery are done for residents. Good quality care may not cost more than poor quality care; there is some evidence that good quality care may cost less. Small facilities of 60 beds were more likely to have good resident outcomes. Strategies have to be considered so larger facilities can be organized into smaller clusters of units that could function as small nursing homes within the larger whole.     

Frontline caregiver daily practices: a comparison study of traditional nursing homes and the Green House project sites

OBJECTIVES: To describe differences in frontline caregiver daily practice in two types of skilled nursing facility (SNF) settings, Green House (GH) homes and traditional SNF units, related to overall staffing (nursing and nonnursing departments), direct care and indirect care time per resident day, and staff time interacting with residents. DESIGN: Observational, interview, and survey study comparing frontline caregiver daily practice in GH homes and traditional SNFs. SETTING: Twenty‐seven sites (GH homes and traditional SNF units). PARTICIPANTS: Two hundred forty staff from participating sites. MEASUREMENTS: Site and resident characteristics, nursing and nonnursing department staff hours per resident day (HPRDs), certified nursing assistant (CNA) direct and indirect care HPRDs, and CNA HPRDs engaged with residents. RESULTS: Staffing from nursing and nonnursing departments combined, excluding administrative, was 0.3 less HPRDs (18 minutes) in GH homes than in traditional SNFs. CNAs in GH homes, although responsible for more nonnursing activities such as laundry and housekeeping, spent 0.4 more HPRDs (24 minutes) in direct care activities than CNAs in traditional SNFs. CONCLUSION: The results challenge the assumption that staffing efficiencies cannot be achieved in small environments such as a GH home. Although the GH model has higher ratio of CNA staff to residents than traditional SNF units, overall staff time (combined total of nursing and nonnursing HPRDs) is slightly less in GH homes. The GH model allows for expanded responsibilities of CNAs in indirect care activities and more time in direct care activities and engaging directly with resident.     

An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing

BACKGROUND: efficient strategies are needed to provide specialist advice in nursing homes to ensure quality medical care. We describe a case conference intervention involving a multidisciplinary team of health professionals. OBJECTIVES: to evaluate the impact of multidisciplinary case conferences on the appropriateness of medications and on patient behaviours in high-level residential aged care facilities. DESIGN: cluster-randomised controlled trial. SETTING: ten high-level aged care facilities. PARTICIPANTS: 154 residents with medication problems and/or challenging behaviours were selected for case conference by residential care staff. INTERVENTION: two multidisciplinary case conferences involving the resident's general practitioner, a geriatrician, a pharmacist and residential care staff were held at the nursing home for each resident. MEASUREMENTS: outcomes were assessed at baseline and 3 months. The primary outcome was the Medication Appropriateness Index (MAI). The behaviour of each resident was assessed via the Nursing Home Behaviour Problem Scale. RESULTS: 45 residents died before follow-up. Medication appropriateness improved in the intervention group [MAI mean change 4.1, 95% confidence interval (CI) 2.1-6.1] compared with the control group (MAI mean change 0.4, 95% CI -0.4-1.2; P < 0.001). There was a significant reduction in the MAI for benzodiazepines (mean change control -0.38, 95% CI -1.02-0.27 versus intervention 0.73, 95% CI 0.16-1.30; P = 0.017). Resident behaviours were unchanged after the intervention and the improved medication appropriateness did not extend to other residents in the facility. CONCLUSION: multidisciplinary case conferences in nursing homes can improve care. Outreach specialist services can be delivered without direct patient contact and achieve improvements in prescribing.     

Assessing resident satisfaction and its relationship to staff satisfaction in residential aged care

Objective: To describe a method for assessing the views of residents in aged care facilities and present the results of modelling the relationships between resident satisfaction and factors related to the staff, the residents and the facilities. Methods: The first stage involved focus groups and interviews with over 400 residents, with staff and management, and consultations with relevant groups. The self‐complete resident satisfaction instrument developed was then administered, in conjunction with other instruments, in a total of 70 aged care facilities. Results: Whilst satisfaction with staff care was found to have a significant positive impact on all aspects of resident satisfaction, staff satisfaction was found to have more influence on resident satisfaction than actual care hours provided, adjusting for resident dependency. Conclusion: Increasing the satisfaction of residents in aged care facilities appears to be particularly related to attending to the factors which influence staff satisfaction, such as status and pay.     

Consumer satisfaction in long-term care: state initiatives in nursing homes and assisted living facilities

PURPOSE: We report the results of a survey of state initiatives that measure resident satisfaction in nursing homes and assisted living facilities, and we describe several model programs for legislators and public administrators contemplating the initiation of their own state programs. DESIGN AND METHODS: Data on state initiatives and programs were collected during March and April 2000 through a mailed questionnaire and follow-up telephone interviews and were current as of September 2002. RESULTS: Of the 50 states surveyed, 50 responses were received (response rate = 100%); 12 states (24%) reported the use of consumer satisfaction measures, and 7 (Florida, Iowa, Ohio, Oregon, Texas, Vermont, and Wisconsin) reported using resident satisfaction data within their consumer information systems for nursing homes or assisted living facilities. Additionally, 2 states (Iowa and Wisconsin) use resident satisfaction data for facility licensing and recertification. The design of the instruments and collection methods vary in these states, as do the reported response rates, per-resident cost, and the purpose for satisfaction data collection. IMPLICATIONS: State satisfaction efforts are in an early stage of development. Well-produced, easily understandable reports on nursing home and assisted living quality could provide information and guidance for patients and families contemplating the utilization of long-term care services. Dissemination of quality information may also facilitate sustained quality and efficiency improvements in long-term care facilities and thus enhance the quality of care for and quality of life of long-term care residents.     

Impact of a falls menu-driven incident-reporting system on documentation and quality improvement in nursing homes

PURPOSE: Data from incident-reporting systems have been used successfully in disciplines other than health care to improve safety. This study tested the effect of a falls menu-driven incident-reporting system (MDIRS) on quality-improvement efforts in nursing homes. DESIGN AND METHODS: Following instrument development and testing, the intervention occurred over a 4-month period in three intervention nursing homes using the MDIRS matched with three homes using their existing narrative incident report to document falls. Data on fall incidents were collected from facility incident reports, and comparisons in incident-report documentation were made between the intervention and control groups. The minutes from quality-improvement meetings were examined to see how incident-report data were used for fall-prevention strategies. RESULTS: Almost one third of nursing home residents among the six facilities fell during the 4-month study period. Intervention nursing homes had significantly better documentation of fall characteristics on the incident reports than did the control nursing homes. Although only one nursing home fully implemented the MDIRS intervention, all three facilities identified strengths of the system. IMPLICATIONS: The MDIRS can have a significant impact in improving how nursing staff assess residents following a fall incident. Traditional narrative methods of documenting adverse incidents are time consuming and may not yield sufficient and accurate data. This model has the potential to enhance quality-improvement efforts and augment the current system of adverse incident reporting in nursing homes.     

Prevalence of Methicillin-Resistant Staphylococcus aureus Colonization in Residents and Staff in Nursing Homes in Northern Ireland

OBJECTIVES: To determine the prevalence of, and factors associated with, methicillin-resistant Staphylococcus aureus (MRSA) colonization in residents and staff in nursing homes in one geographically defined health administration area of Northern Ireland.
DESIGN: Point prevalence study.
SETTING: Nursing homes.
PARTICIPANTS: Residents and staff in nursing homes.
MEASUREMENTS: Nasal swabs were taken from all consenting residents and staff. If relevant, residents also provided urine samples, and swabs were taken from wounds and indwelling devices.
RESULTS: A total of 1,111 residents (66% of all residents) and 553 staff (86% of available staff) in 45 nursing homes participated. The combined prevalence rate of MRSA in the resident population was 23.3% (95% confidence interval (CI)=18.8–27.7%) and 7.5% in staff (95% CI=5.1–9.9%). Residents who lived in nursing homes that were part of a chain were more likely to be colonized with MRSA (odds ratio (OR)=1.91, 95% CI=1.21–3.02) than those living in independently owned facilities. Residents were also more likely to be colonized if they lived in homes in which more than 12.5% of all screened healthcare staff (care assistants and nurses) were colonized with MRSA (OR=2.46, 95% CI=1.41–4.29) or if they lived in homes in which more than 15% of care assistants were colonized with MRSA (OR=2.64, 95% CI=1.58–4.42).
CONCLUSION: The findings suggest that there is substantial colonization of MRSA in nursing home residents and staff in this one administrative health area. Implementation of infection control strategies should be given high priority in nursing homes.     

Dependence and Independence in the Hostel

This study examined the level of independence/dependence of 233 elderly persons domiciled in Brisbane. Subjects were drawn from both elderly persons living in their own homes (n=75) and elderly persons residing in hostels (n=158). The study investigated the relationship between the environments of elderly persons and their level of independence. As anticipated, significant differences were found on the Iowa Self-Assessment Inventory (ISAI) scores between the own home group and the hostel group. On the basis of a survey of Queensland hostels using the Institutional Regimes Questionnaire (IRQ), eleven hostels were classified as having positive regimes or restrictive regimes. The ISAI scores of 85 ‘positive regimes’ hostel residents and the 73 ‘restrictive regimes’ hostel residents were then examined. A significant difference was found between residents living in their own home and hostel residents. However, the results indicated that regimes, as measured by the IRQ, could not be used to differentiate the independence level of hostel residents. The level of dependence of residents in hostels with restrictive management regimes was no different from the level of independence of residents in hostels with positive management regimes.     

The potential of wash-and-dry toilets to improve the toileting experience for nursing home residents

PURPOSE: We investigated the feasibility of using a "wash-and-dry" toilet in the nursing home. DESIGN AND METHODS: We used a controlled comparison baseline-versus-treatment design with 22 female nursing home residents aged 75 and older living in a 562-bed, not-for-profit nursing home facility in Maryland. The Luscence Luxury Lavage wash-and-dry toilet-bidet system was installed in the bathrooms of the experimental group. Measurements included staff and resident toilet experiences and toilet reaction questionnaires, utilization logs, Minimum Data Set information, Mini-Mental State Examination scores, and urine cultures. RESULTS: About half of the residents and staff members reported the toilet to have a positive effect on toileting. We saw a positive trend in resident affect for the experimental group that was not apparent for the comparison group. Nursing staff reported that the toilet functions did clean the residents, but that cleaning was not complete. Bacterial content of urine decreased in the experimental group and increased in the comparison group during the trial. Toilet installation was more complex than anticipated. IMPLICATIONS: These results show that a wash-and-dry toilet shows promise for improved resident comfort in toileting and cleanliness, although further research is needed to verify the findings. Improved toilet design, design of nursing homes, and design of care activities would all improve the utility of these toilets in the nursing home population.     

Challenges to Achieving Adequate Sample Sizes for Facility Level Evaluations of Nursing Home Resident Satisfaction

Residents with cognitive limitations by necessity are excluded from nursing home satisfaction initiatives. We used national data from the Minimum Data Set (MDS) to examine the distribution of resident cognitive status across nursing homes to gain further insight into how residents with cognitive limitations could impact the sample size of respondents. We estimate the associations of cognitive status (using the MDS Cognitive Performance Scale, [CPS]) with length-of-stay, bed size, and hospital affiliation. The analyses were performed using approximately 3.5 million MDS records collected from nursing homes during 2001. The results show adequately precise information for long-stay residents will be available from 4 to 46% of hospital-based facilities and 67–90% of freestanding facilities, whereas information from short-stay residents will be available from 34 to 95% of hospital-based facilities and 14–50% of freestanding facilities. Several initiatives are underway to measure and report the satisfaction of nursing home residents. In all of these large satisfaction initiatives the sampling strategy of respondents needs to be sufficient to allow for nursing home comparisons, and second, to allow interfacility benchmarking comparisons. We highlight the difficulty in obtaining information for these initiatives.     

Informal caregiver involvement and illness detection among cognitively impaired nursing home residents

BACKGROUND: The participation of informal caregivers in the care of nursing home (NH) residents has the potential to positively impact care, especially for cognitively impaired residents whose own ability to advocate for their care is often limited. This study examined relationships between the level of informal caregiver involvement (ICI) in the NH and the degree to which residents' common medical conditions were detected by facility staff. METHODS: One hundred pairs of cognitively impaired residents and their primary informal caregivers were enrolled from three facilities in the Baltimore, Maryland area. Data collection involved interviews with informal caregivers and facility staff, as well as a medical evaluation and chart review of residents. A measure of illness detection was created by comparing a medical examination of the resident with chart review information. ICI was measured via staff rating and informal caregiver self-report. RESULTS: Correlations between illness detection and ICI were significant, with r = -.46 (p <.001) and r = -.39 (p <.001), for staff rating and self-reports, respectively. In regression models taking into account resident characteristics (age, race, gender, comorbidities, payment status, duration of stay, and cognitive impairment) and facility differences, higher ICI and being female predicted higher rates of illness detection. CONCLUSIONS: Though the cross-sectional nature of the study prevents the analysis of causal relationships, the involvement level of informal caregivers in the NH care of cognitively impaired residents was statistically related to higher rates of illness detection. Ramifications for the role of informal caregivers in long-term care are discussed.     

Nursing home facility risk factors for infection and hospitalization: importance of registered nurse turnover,administration, and social factors

OBJECTIVES: Determine the relationship between a broad array of structure and process elements of nursing home care and (a) resident infection and (b) hospitalization for infection. DESIGN: Baseline data were collected from September 1992 through March 1995, and residents were followed for 2 years; facility data were collected at the midpoint of follow-up. SETTING: A stratified random sample of 59 nursing homes across Maryland. PARTICIPANTS: Two thousand fifteen new admissions aged 65 and older. MEASUREMENTS: Facility-level data were collected from interviews with facility administrators, directors of nursing, and activity directors; record abstraction; and direct observation. Main outcome measures included infection (written diagnosis, a course of antibiotic therapy, or radiographic confirmation of pneumonia) and hospitalization for infection (indicated on medical records). RESULTS: The 2-year rate of infection was 1.20 episodes per 100 resident days, and the hospitalization rate for infection was 0.17 admissions per 100 resident days. Except for registered nurse (RN) turnover, which related to both infection and hospitalization, different variables related to each outcome. High rates of incident infection were associated with more Medicare recipients, high levels of physical/occupational therapist staffing, high licensed practical nurse staffing, low nurses' aide staffing, high intensity of medical and therapeutic services, dementia training, staff privacy, and low levels of psychotropic medication use. High rates of hospitalization for infection were associated with for-profit ownership, chain affiliation, poor environmental quality, lack of resident privacy, lack of administrative emphasis on staff satisfaction, and low family/friend visitation rates. Adjustment for resident sex, age, race, education, marital status, number of morbid diagnoses, functional status, and Resource Utilization Group, Version III score did not alter the relationship between the structure and process of care and outcomes. CONCLUSIONS: The association between RN turnover and both outcomes underscores the relationship between nursing leadership and quality of care in these settings. The relationship between hospitalization for infection and for-profit ownership and chain affiliation could reflect policies not to treat acute illnesses in house. The link between social factors of care (environmental quality, prioritizing staff satisfaction, resident privacy, and facility visitation) and hospitalization indicates that a nonmedical model of care may not jeopardize, and may in fact benefit, health-related outcomes. All of these facility characteristics may be modifiable, may affect healthcare costs, and may hold promise for other, less-medical, forms of residential long-term care.     

Partners in caregiving in a special care environment: cooperative communication between staff and families on dementia units

PURPOSE: This article reports the results of a randomized, controlled evaluation of Partners in Caregiving in a Special Care Environment, an intervention designed to improve communication and cooperation between staff and families of residents in nursing home dementia programs. DESIGN AND METHODS: Participants included 388 family members and 384 nursing staff members recruited from 20 nursing homes, randomly assigned to treatment and control conditions. Project staff conducted training sessions on communication and conflict-resolution techniques with two groups at the intervention sites: staff and residents' family members, followed by a joint meeting with facility administrators. RESULTS: Families, staff, residents, and facility programs in the intervention facilities all demonstrated positive outcomes from program participation. Families experienced significant improvement in communicating with staff and in staff behaviors toward them, and spouses of residents increased their care involvement. Staff reported reduced conflict with families and reduced depression; burnout for nurses increased for individuals in the control group but not those in the treatment group. Behavioral symptoms decreased for residents, and facilities implemented more family-focused programs. IMPLICATIONS: Effective staff and family partnerships are critical in caring for residents with dementia. The Partners in Caregiving in a Special Care Environment program is an evidence-based intervention that enables these partnerships to develop and thrive, translating into improved experiences for residents, families, and staff.     

Resident-to-resident aggression in long-term care facilities: insights from focus groups of nursing home residents and staff

OBJECTIVES: To more fully characterize the spectrum of resident‐to‐resident aggression (RRA). DESIGN: A focus group study of nursing home staff members and residents who could reliably self‐report. SETTING: A large, urban, long‐term care facility. PARTICIPANTS: Seven residents and 96 staff members from multiple clinical and nonclinical occupational groups. MEASUREMENTS: Sixteen focus groups were conducted. Content was analyzed using nVivo 7 software for qualitative data. RESULTS: Thirty‐five different types of physical, verbal, and sexual RRA were described, with screaming or yelling being the most common. Calling out and making noise were the most frequent of 29 antecedents identified as instigating episodes of RRA. RRA was most frequent in dining and residents' rooms, and in the afternoon, although it occurred regularly throughout the facility at all times. Although no proven strategies exist to manage RRA, staff described 25 self‐initiated techniques to address the problem. CONCLUSION: RRA is a ubiquitous phenomenon in nursing home settings, with important consequences for affected individuals and facilities. Further epidemiological research is necessary to more fully describe the phenomenon and identify risk factors and preventative strategies.     

A preliminary evaluation of the paid feeding assistant regulation: impact on feeding assistance care process quality in nursing homes

PURPOSE: The Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality sponsored a nationwide study to evaluate the federal paid feeding assistant (PFA) regulation that allows nursing homes to hire single-task workers to provide feeding assistance to nursing home residents. Organizers designed the PFA regulation to increase the number of staff available to provide assistance with eating and improve nutritional care process quality. DESIGN AND METHODS: Trained research staff used standardized protocols to conduct direct observations during meals and face-to-face staff interviews in a convenience sample of seven facilities with PFA programs to evaluate care process quality. RESULTS: Most (84%) of the trained PFAs in the seven site visit facilities were non-nursing staff within the facility; the quality of feeding assistance care provided by these workers was comparable to that provided by indigenous nurse aides. There were no reported changes in existing staffing levels (nurse aide or licensed nurses) following PFA program implementation, and the majority (> 90%) of indigenous staff at all levels reported positive benefits of the PFA program for both staff and residents. IMPLICATIONS: Findings from this preliminary study indicate that the PFA regulation may serve to increase the utilization of existing non-nursing staff to improve feeding assistance care during meals without having a negative impact on existing nurse aide and licensed nurse staffing levels.