Relationship of nursing home staffing to quality of care

OBJECTIVE: To compare nursing homes (NHs) that report different staffing statistics on quality of care. DATA SOURCES: Staffing information generated by California NHs on state cost reports and during onsite interviews. Data independently collected by research staff describing quality of care related to 27 care processes. STUDY DESIGN: Two groups of NHs (n=21) that reported significantly different and stable staffing data from all data sources were compared on quality of care measures. DATA COLLECTION: Direct observation, resident and staff interview, and chart abstraction methods. PRINCIPAL FINDINGS: Staff in the highest staffed homes (n=6), according to state cost reports, reported significantly lower resident care loads during onsite interviews across day and evening shifts (7.6 residents per nurse aide [NA]) compared to the remaining homes that reported between 9 to 10 residents per NA (n=15). The highest-staffed homes performed significantly better on 13 of 16 care processes implemented by NAs compared to lower-staffed homes. CONCLUSION: The highest-staffed NHs reported significantly lower resident care loads on all staffing reports and provided better care than all other homes.     

Comparison of two different approaches for the application of the mini nutritional assessment in nursing homes: Resident interviews versus assessment by nursing staff

Background

When the Mini Nutritional Assessment (MNA©) was developed, the authors did not specifically focus on the nursing home setting. Due to a number of particularities of nursing home residents, such as cognitive and linguistic disabilities, a number of uncertainties with regard to its application await clarification.

Aims and objectives

The aim of this study was to compare the results of two different modes of MNA application in nursing homes: resident interviews versus assessment by nursing staff.

Method

The MNA was applied to 200 residents of two municipal nursing homes in Nuremberg, Germany. First one-on-one interviews of the residents were conducted by two researchers from our group. Next, the MNA was applied by the attending nursing staff who was blinded to the results of the first MNA. To evaluate the prognostic properties of the two different approaches, data on mortality of the screened residents were collected during a six-month follow-up period.

Results

Among 200 residents (f 147 m 53, f 86.5±7.4 y. m 83.0±8.5 y.), the MNA could be applied t 138 residents (69. 0%) by one-on-one interviews and to 188 residents (94.0%) by the nursing staff. 15.2% of the residents were categorised as malnourished by the interviews and 8.7% by the nursing staff’s assessment. The agreement of the two forms was low for the MNA short form (weighted kappa = 0.31; 95% CI: 0.14 ? 0.47) as well as for the full MNA (weighted kappa = 0.35; 95% CI: 0.27 ? 0.44). After exclusion of residents with cognitive impairment (n=89), agreement for the full version increased (weighted kappa = 0.47, 95% CI 0. 25 ? 0.68). 25 (12.5%) study participants deceased during the follow-up period. Mortality was significantly associated with the mortality for both approaches, while the MNA application by the nursing staff proved to be superior (nursing staff p<0.001, residents p<0.05).

Conclusions

The results of the MNA in nursing home residents may differ substantially when resident interviews are compared to assessment by nursing staff. The authors recommend that the MNA should be routinely applied by the nursing staff. The application rate is higher and interference with cognitive as well as linguistic deficits is lower. In future studies, the mode of MNA application in nursing home residents should be clearly stated to facilitate comparability of results.     

Violence exposure and burn-out among Turkish nursing home staff

AIM: The aim of this study was to describe the frequency of violence against personnel from residents and to identify the prevalence of burn-out among staff working in nursing homes. METHODS: The study was performed in two cities in the west of Turkey. A semi-structured questionnaire on violence and Pines' Burnout scale were distributed among all the staff working in six nursing homes, and 214 of them responded. RESULTS: Of the total number of respondents, 56% stated that they had been exposed to violence during the preceding year. More than 20% stated that they had reported violence to their supervisor. Less than 10% had received medical or psychological support following the event. Violent incidents were reported significantly more frequently among staff who reported problems working with elderly residents. There was no relationship between violence towards staff and burn-out. CONCLUSIONS: Violence is commonly experienced by care workers in nursing homes for the elderly. Strategies to improve occupational conditions in nursing homes are required.     

Living and dying: responsibility for end‐of‐life care in care homes without on‐site nursing provision ‐ a prospective study

The aim of the study was to describe the expectations and experiences of end‐of‐life care of older people resident in care homes, and how care home staff and the healthcare practitioners who visited the care home interpreted their role. A mixed‐method design was used. The everyday experience of 121 residents from six care homes in the East of England were tracked; 63 residents, 30 care home staff with assorted roles and 19 National Health Service staff from different disciplines were interviewed. The review of care home notes demonstrated that residents had a wide range of healthcare problems. Length of time in the care homes, functional ability or episodes of ill‐health were not necessarily meaningful indicators to staff that a resident was about to die. General Practitioner and district nursing services provided a frequent but episodic service to individual residents. There were two recurring themes that affected how staff engaged with the process of advance care planning with residents; ‘talking about dying’ and ‘integrating living and dying’. All participants stated that they were committed to providing end‐of‐life care and supporting residents to die in the care home, if wanted. However, the process was complicated by an ongoing lack of clarity about roles and responsibilities in providing end‐of‐life care, doubts from care home and primary healthcare staff about their capacity to work together when residents’ trajectories to death were unclear. The findings suggest that to support this population, there is a need for a pattern of working between health and care staff that can encourage review and discussion between multiple participants over sustained periods of time.     

Knowledge of and Perceived Need for Evidence-Based Education About Antipsychotic Medications Among Nursing Home Leadership and Staff

Background/Objectives

Antipsychotic use is common in US nursing homes, despite evidence of increased risk of morbidity and mortality, and limited efficacy in older adults with dementia. Knowledge, attitudes, and beliefs regarding antipsychotic use among nursing home staff are unclear. The study aim was to describe nursing home leadership and direct care staff members’ knowledge of antipsychotic risks, beliefs and attitudes about the effectiveness of antipsychotics and nonpharmacologic management of dementia-related behaviors, and perceived need for evidence-based training about antipsychotic medication safety.

Design, Setting, Participants, and Measurements

Survey of leadership and direct care staff of nursing homes in Connecticut was conducted in June 2011. Questionnaire domains included knowledge of antipsychotic risks, attitudes about caring for residents with dementia, satisfaction with current behavior management training, beliefs about antipsychotic effectiveness, and need for staff training about antipsychotics and behavior management.

Results

A total of 138 nursing home leaders and 779 direct care staff provided useable questionnaires. Only 24% of nursing home leaders identified at least 1 severe adverse effect of antipsychotics; 13% of LPNs and 12% of RNs listed at least 1 severe adverse effect. Fifty-six percent of direct care staff believed that medications worked well to manage resident behavior. Leaders were satisfied with the training that staff received to manage residents with challenging behaviors (62%). Fifty-five percent of direct care staff felt that they had enough training on how to handle difficult residents; only 37% felt they could do so without using medications.

Conclusions

Findings suggest that a comprehensive multifaceted intervention designed for nursing homes should aim to improve knowledge of antipsychotic medication risks, change beliefs about appropriateness and effectiveness of antipsychotics for behavior management, and impart strategies and approaches for nonpharmacologic behavior management.     

Long-term care. Unknown quantities

A small study of nursing home owners, managers, residents and relatives found effective management depended on strong leadership skills, high bed occupancy, enthusiastic staff and low staff turnover. Funding problems were a key issue for homes, creating massive insecurity for residents, relatives and staff. There was a feeling that nursing homes could be used more effectively by the NHS, but there were concerns about capacity and competence. The viability of homes would be improved by annual block booking by the NHS. This would also facilitate the development of intermediate care. A national development programme for nursing home managers is needed.     

The effect of Medicaid reimbursement on quality of care in nursing homes

This study uses a nationally representative sample of nursing homes and nursing home residents to examine the effect of Medicaid reimbursement on quality of care. The analysis shows that both reimbursement approach and level affect nursing home quality, as measured by case-mix adjusted staff to resident ratios. The analysis also shows that staffing ratios have a significant impact on resident outcomes, and these impacts vary by professional category of staff. Reimbursement does not have a significant impact on outcomes, however.     

Autonomy Support of Nursing Home Residents With Dementia in Staff-Resident Interactions: Observations of Care

ObjectivesPeople with dementia living in nursing homes benefit from a social environment that fully supports their autonomy. Yet, it is unknown to what extent this is supported in daily practice. This study aimed to explore to which extent autonomy is supported within staff–resident interactions.DesignAn exploratory, cross-sectional study.Setting and ParticipantsIn total, interactions between 57 nursing home residents with dementia and staff from 9 different psychogeriatric wards in the Netherlands were observed.MethodsStructured observations were carried out to assess the support of resident autonomy within staff–resident interactions. Observations were performed during morning care and consisted of 4 main categories: getting up, physical care, physical appearance, and breakfast. For each morning care activity, the observers consecutively scored who initiated the care activity, how staff facilitated autonomy, how residents responded to staff, and how staff reacted to residents’ responses. Each resident was observed during 3 different mornings. In addition, qualitative field notes were taken to include environment and ambience.ResultsIn total, 1770 care interactions were observed. Results show that autonomy seemed to be supported by staff in 60% of the interactions. However, missed opportunities to engage residents in choice were frequently observed. These mainly seem to occur during interactions in which staff members took over tasks and seemed insensitive to residents’ needs and wishes. Differences between staff approach, working procedures, and physical environment were observed across nursing home locations.Conclusions and ImplicationsThe findings of this study indicate that staff members support resident autonomy in more than one-half of the cases during care interactions. Nonetheless, improvements are needed to support resident autonomy. Staff should be encouraged to share and increase knowledge in dementia care to better address residents’ individual needs. Especially for residents with severe dementia, it seems important that staff develop skills to support their autonomy.     

The Influence of Teams to Sustain Quality Improvement in Nursing Homes that “Need Improvement”

ObjectivesQualitatively describe the use of team and group processes in intervention facilities participating in a study targeted to improve quality of care in nursing homes “in need of improvement.”Design/setting/participantsA randomized, two-group, repeated-measures design was used to test a 2-year intervention for improving quality of care and resident outcomes. Intervention group (n = 29) received an experimental multilevel intervention designed to help them: (1) use quality improvement methods, (2) use team and group process for direct-care decision-making, (3) focus on accomplishing the basics of care, and (4) maintain more consistent nursing and administrative leadership committed to communication and active participation of staff in decision-making.ResultsThe qualitative analysis revealed a subgroup of homes (“Full Adopters”) likely to continue quality improvement activities that were able to effectively use teams. “Full Adopters” had either the nursing home administrator or director of nursing who supported and were actively involved in the quality improvement work of the team. “Full Adopters” also selected care topics for the focus of their quality improvement team, instead of “communication” topics of the “Partial Adopters” or “Non-Adopters” in the study who were identified as unlikely to continue to continue quality improvement activities after the intervention. “Full Adopters” had evidence of the key elements of complexity science: information flow, cognitive diversity, and positive relationships among staff; this evidence was lacking in other subgroups. All subgroups were able to recruit interdisciplinary teams, but only those that involved leaders were likely to be effective and sustain team efforts at quality improvement of care delivery systems.ConclusionsResults of this qualitative analysis can help leaders and medical directors use the key elements and promote information flow among staff, residents, and families; be inclusive as discussions about care delivery, making sure diverse points of view are included; and help build positive relationships among all those living and working in the nursing home. Wide-spread adoption of the intervention in the randomized study is feasible and could be enabled by nursing home Medical Directors in collaborative practice with Advanced Practice Nurses.     

Optimizing antibiotics in residents of nursing homes: protocol of a randomized trial

BACKGROUND: Antibiotics are frequently prescribed for older adults who reside in long-term care facilities. A substantial proportion of antibiotic use in this setting is inappropriate. Antibiotics are often prescribed for asymptomatic bacteriuria, a condition for which randomized trials of antibiotic therapy indicate no benefit and in fact harm. This proposal describes a randomized trial of diagnostic and therapeutic algorithms to reduce the use of antibiotics in residents of long-term care facilities. METHODS: In this on-going study, 22 nursing homes have been randomized to either use of algorithms (11 nursing homes) or to usual practise (11 nursing homes). The algorithms describe signs and symptoms for which it would be appropriate to send urine cultures or to prescribe antibiotics. The algorithms are introduced by inservicing nursing staff and by conducting one-on-one sessions for physicians using case-scenarios. The primary outcome of the study is courses of antibiotics per 1000 resident days. Secondary outcomes include urine cultures sent and antibiotic courses for urinary indications. Focus groups and semi-structured interviews with key informants will be used to assess the process of implementation and to identify key factors for sustainability.     

Randomized multilevel intervention to improve outcomes of residents in nursing homes in need of improvement

ObjectivesA comprehensive multilevel intervention was tested to build organizational capacity to create and sustain improvement in quality of care and subsequently improve resident outcomes in nursing homes in need of improvement.Design/Setting/ParticipantsIntervention facilities (N = 29) received a 2-year multilevel intervention with monthly on-site consultation from expert nurses with graduate education in gerontological nursing. Attention control facilities (N = 29) that also needed to improve resident outcomes received monthly information about aging and physical assessment of elders.InterventionThe authors conducted a randomized clinical trial of nursing homes in need of improving resident outcomes of bladder and bowel incontinence, weight loss, pressure ulcers, and decline in activities of daily living. It was hypothesized that following the intervention, experimental facilities would have higher quality of care, better resident outcomes, more organizational attributes of improved working conditions than control facilities, higher staff retention, similar staffing and staff mix, and lower total and direct care costs.ResultsThe intervention did improve quality of care (P = .02); there were improvements in pressure ulcers (P = .05) and weight loss (P = .05). Organizational working conditions, staff retention, staffing, and staff mix and most costs were not affected by the intervention. Leadership turnover was surprisingly excessive in both intervention and control groups.Conclusion and ImplicationsSome facilities that are in need of improving quality of care and resident outcomes are able to build the organizational capacity to improve while not increasing staffing or costs of care. Improvement requires continuous supportive consultation and leadership willing to involve staff and work together to build the systematic improvements in care delivery needed. Medical directors in collaborative practice with advanced practice nurses are ideally positioned to implement this low-cost, effective intervention nationwide.     

Multiresistant pathogens in geriatric nursing – infection control in residential facilities for geriatric nursing in Germany

Background: The increase of multidrug-resistant organisms (MDROs) causes problems in geriatric nursing homes. Older people are at increased a growing risk of infection due to multimorbidity and frequent stays in hospital. A high proportion of the elderly require residential care in geriatric nursing facilities, where hygiene requirements in nursing homes are similar to those in hospitals. For this reason we examined how well nursing homes are prepared for MDROs and how effectively protect their infection control residents and staff.Methods: A cross-sectional study was performed on infection control in residential geriatric nursing facilities in Germany 2012. The questionnaire recorded important parameters of hygiene, resident and staff protection and actions in case of existing MDROs.Results: The response was 54% in Hamburg and 27% in the rest of Germany. Nursing homes were generally well equipped for dealing with infection control: There were standards for MDROs and regular hygiene training for staff. The facilities provided adequate protective clothing, affected residents are usually isolated and hygienic laundry processing conducted. There are deficits in the communication of information on infected residents with hospitals and general practitioners. 54% of nursing homes performed risk assessments for staff infection precaution.Conclusion: There is a growing interest in MDROs and infection control will be a challenge in for residential geriatric nursing facilities in the future. This issue has also drawn increasing attention. Improvements could be achieved by improving communication between different participants in the health service, together with specific measures for staff protection at work.     

Purchasing High-Quality Community Nursing Home Care: A Will to Work With VHA Diminished by Contracting Burdens

ObjectivesThe Veterans Health Administration (VHA) purchases community nursing home care; however, the administrative burden may lead nursing homes to avoid contracting with the VHA. This study aimed to describe how the VHA's purchasing policies impede or facilitate contracting with nursing homes.DesignSemistructured interviews of key stakeholders in the VHA's community nursing home contracting process.Setting and ParticipantsWe interviewed 15 VHA and 21 nursing home staff at 6 VHA medical centers and 17 nursing homes. VHA medical centers were selected from sites with the greatest magnitude of difference in quality rankings between VHA contracted and noncontracted nursing homes in the same market area.MethodsQualitative content analysis of interviews.ResultsFive themes emerged: (1) VHA purchases nursing home care to fill gaps in geographic, specialty, and quality care needs; (2) business opportunities and the mission to care for Veterans motivate nursing homes to work with the VHA; (3) the VHA's reputation for unreliable or insufficient payment and inability of nursing homes to comply with federal wage standards serve as barriers to establishing contracts; (4) complexity of establishing a contract, ambiguity about new policies, and inadequate VHA staffing for the nursing home inspection team hinder the VHA's ability to establish contracts with nursing homes; and (5) nursing homes that have established corporate processes, nursing home administrators with prior experience working with the VHA, and relationships between VHA and nursing home staff serve as facilitators to establishing new nursing home contracts.Conclusions and ImplicationsNursing homes will work with the VHA, but the process of executing VHA contracts is burdensome. Streamlining and standardizing the purchasing processes and ensuring timely payment may expand the number of nursing homes willing to contract with the VHA, thereby increasing choices for Veterans and becoming a model for other long-term care networks.     

Dependency, quality and staffing of institutions for elderly people

There have been dramatic changes in residential and nursing care of elderly people in the community over the last decade. Despite this, little is known about how these institutions compare in terms of: the quality of care they provide to residents; the dependency of the residents; or the manpower levels and qualifications of the staff employed. This study was undertaken with the aim of comparing the public and private sectors providing care to elderly people. A random selection of institutions was invited to participate, including private residential and nursing homes, Social Services homes and National Health Services long-term care wards. The findings show that the dependency of residents in the public sector was greater than in the private sector, with more mentally confused, incontinent and socially disengaged residents in the public sector. The staff to resident ratio in public institutions did not differ significantly from the private sector. Overall scores of quality of care were similar. Nevertheless, these scores masked important differences between the sectors, eg poorer buildings and facilities characterised the National Health Service units. Fewer activities and therapies, but a better ambience, was noted in the private nursing homes. These results suggest that the outcome of a policy to transfer the most heavily dependent patients from the care of the public sector could increasingly burden the private sector. This would result increase the proportion of highly dependent residents, with no clear provision for improved staff ratios, quality of care or training of staff.     

Prevalence of influenza vaccination in South Australian aged care homes

OBJECTIVE: To determine the prevalence of influenza immunisation of residents within South Australian aged care homes, reasons why vaccination is not given, the policy associated with vaccination administration and the source of the vaccination. METHOD: A clustered, multistage, area sample was used to assess the provision of the influenza vaccine to 500 randomly selected residents within 50 randomly selected aged care homes in South Australia during face-to-face interviews with the director of nursing at each of the selected facilities. The response rate was 100%. RESULTS: Overall, 88.4% (95% CI 85.2-91.0) of residents had received an influenza immunisation in 2001. The reasons why a resident did not have an influenza vaccination included refusal and allergy. Consent was generally obtained on an ad hoc basis (in 94.0% of homes) with the most frequent form of consent type being verbal (66.0%). Influenza vaccine administration was part of standing drug orders in 16.0% of cases and over half of the homes (54.0%) had a specific policy of education and encouraging both residents and staff to be vaccinated against influenza. CONCLUSION: Residents of aged care homes, a population deemed to be at high risk of contracting influenza, are receiving an adequate level of influenza coverage although improvements could be made. Addressing policy and procedural issues can maintain, and further improve, vaccination levels. IMPLICATIONS: Clarification of policies for influenza vaccination administration particularly in regard to staff could further improve rates of vaccination coverage.