The relationship between quality and staffing in long-term care: A systematic review of the literature 2008-2020

Organizational Context and Facilitation Interactions on Delirium Risk in Long-Term Care: A Cross-Sectional Study

OBJECTIVES

Organizational context (eg, leadership) and facilitation (eg, coaching behaviors) are thought to interact and influence staff best practices in long-term care (LTC), including the management of delirium. Our objective was to assess if organizational context and facilitation-individually, and their interactions-were associated with delirium in LTC.

DESIGN

Retrospective cross-sectional analysis of secondary data.

SETTING AND PARTICIPANTS

We included 8755 residents from 281 care units in 86 LTC facilities in 3 Canadian provinces.

METHODS

Delirium (present/absent) was assessed using the Resident Assessment Instrument-Minimum Data Set 2.0 (RAI-MDS 2.0). The Alberta Context Tool (ACT) measured 10 modifiable features of care unit organizational context. We measured the care unit's total care hours per resident day and the proportion of care hours that care aides contributed (staffing mix). Facilitation included the facility manager's perception of RAI-MDS reports' adequacy and pharmacist availability. We included unit managers' change-oriented organizational citizenship behavior (OCB) and an item reflecting how often care aides recommended policy changes. Associations of organizational context, facilitation, and their interactions with delirium were analyzed using mixed-effects logistic regressions, controlling for covariates.

RESULTS

Delirium symptoms were prevalent in 17.4% of residents (n = 1527). Manager-perceived adequacy of RAI-MDS reports was linked to reduced delirium symptoms [odds ratio (OR) = 0.63]. Higher care hours per resident day (OR = 1.2) and an available pharmacist in the facility (OR = 1.5) were associated with increased delirium symptoms. ACT elements showed no direct association with delirium. However, on care units with low social capital scores (context), increased unit managers' OCB decreased delirium symptoms. On care units with high vs low evaluation scores (context), increased staffing mix reduces delirium symptoms more substantially.

CONCLUSIONS AND IMPLICATIONS

Unit-level interactions between organizational context and facilitation call for targeted quality improvement interventions based on specific contextual factors, as effectiveness may vary across contexts.

Relationship between staff and quality of care in care homes: StaRQ mixed methods study

Background

Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence.

Objective(s)

To explore variations in the care home nursing and support workforce; how resident and relatives' needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents' needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers.

Design

Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 - two evidence syntheses (one realist); WP2 - cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 - analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 - secondary analysis of care home regulator reports; WP5 - social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model.

Setting

English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings.

Participants

Managers, residents, families and care home staff.

Findings

Staffing's contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop 'familial' relationships between staff and residents, and staff-staff reciprocity, 'knowing' residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act. Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged.

Limitations

Many of our findings stem from self-reported and routine data with known biases - such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes.

Conclusions

Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible - rather than available - inputs and outcomes.

Study registration

This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/144/29) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

Study protocol for the development, trial, and evaluation of a strategy for the implementation of qualification-oriented work organization in nursing homes

BACKGROUND

Staffing ratios in nursing homes vary among the federal states of Germany, but there are no rational grounds for these variations. In a previous study, a new instrument for the standardized calculation of staffing requirements in nursing homes was developed (Algorithm 1.0). The development was based on a new empirical data collection method that derives actual and target values for the time and number of care interventions provided. Algorithm 1.0 found an increased requirement of 36% of staff in German nursing homes. Based on these results, the German legislature has commissioned a model program to trial and evaluate a complex intervention comprising increased staffing combined with strategies for organizational development.

METHODS

The mixed-methods study consists of (i) developing a concept for restructuring the work organization, (ii) the application of this concept combined with increased staffing in 10 nursing homes (complex intervention), and the further development of the concept using a participatory and iterative formal evaluation process. The intervention consists of (a) quantitative measures of increased staffing based on a calculation using Algorithm 1.0 and (b) qualitative measures regarding organizational development. The intervention will be conducted over one year. The effects of the intervention on job satisfaction and quality of care will be evaluated in (iii) a comprehensive prospective, controlled summative evaluation. The results will be compared with ten matched nursing homes as a control group. Finally, (iv) prototypical concepts for qualification-oriented work organization, a strategy for the national rollout, and the further development of Algorithm 1.0 into Algorithm 2.0 will be derived.

DISCUSSION

In Germany, there is an ongoing dynamic legislation process regarding further developing the long-term care sector. The study, which is the subject of the study protocol presented here, generates an evidence-based strategy for the staffing requirements for nursing homes.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of the German Association of Nursing Science (Deutsche Gesellschaft für Pflegewissenschaft) on 02.08.2023 (amended on 20.09.2023). Research findings are disseminated through presentations at national and international conferences and publications in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

German Clinical Trails Register DRKS00031773 (Date of registration 09.11.2023).

The role of professional identity and job satisfaction in paediatric nurses' intention to remain employed amidst the COVID-19 pandemic

The COVID-19 pandemic has significantly affected nursing, as nurses are crucial in providing healthcare services. Understanding the factors influencing nurse retention is essential for maintaining a strong and long-lasting workforce because nurse retention is becoming increasingly complex. This study aimed to investigate the influence of professional identity and job satisfaction on the intention to remain employed while also evaluating the levels of professional identity, job satisfaction, and intention to stay among paediatric nurses amidst the COVID-19 pandemic. This correlational and descriptive study included a stratified sample of 257 paediatric nurses and was guided by the STROBE checklist. Data were collected through valid and reliable questionnaires, which included a nurses' professional identity scale, job satisfaction survey, intention to stay scale, and a demographic questionnaire. Data collection was conducted from January to April 2022. The study was approved by the ethical research committee at the Nursing Faculty - Mansoura University, ensuring adherence to the Helsinki Declaration. The paediatric nurses reported elevated professional identity, moderate job satisfaction, and moderate intention to stay employed with mean scores of 80.35 ± 13.22, 113.70 ± 19.58, and 8.40 ± 3.55, respectively. Multiple regression explained 13.0% of the variation in paediatric nurses' intention to remain employed (F = 18.50, p < 0.001). Professional identity positively correlated with the intention to stay (β = 2.69, p = 0.008). Job satisfaction also had a positive relationship with the intention to stay (β = 3.49, p < 0.001). Healthcare managers should focus on professional identity strategies such as supportive work environments, growth opportunities, and valuing paediatric nurses' contributions. Implementing interventions such as fair compensation, support, and rewards can enhance paediatric nurses' retention and quality of patient care.

Factors Affecting COVID-19 Incidences and Deaths of Geriatric Hospital Patients in Korea

The current retrospective study aimed to investigate the association between organizational factors and nursing staff in geriatric hospitals and coronavirus disease 2019 (COVID-19) incidences and deaths using secondary data from governments nationwide in Korea. We used data on the number of COVID-19-confirmed cases and deaths among older adults in geriatric hospitals and nursing staff levels in those hospitals. We found that when the RN level was higher than the sample mean, the number of COVID-19-confirmed cases by geriatric hospital was significantly lower (4.3%; p = 0.05) and the number of deaths by geriatric hospital was marginally significantly lower (1.4%; p = 0.05). This study presented the national description of geriatric hospitals during the COVID-19 pandemic in terms of organizational and nursing staff factors. Findings highlight the impact of nursing staff skill mix and number of geriatric hospitals during the COVID-19 pandemic in Korea. It is necessary to allocate a realistic designation of infection control staff and establish a clear standard so infection control activities in geriatric hospitals can proceed systematically. [Research in Gerontological Nursing, 16(6), 302-311.].

Longitudinal Associations of Staff Shortages and Staff Levels with Health Outcomes in Nursing Homes

OBJECTIVES

To examine whether facility-reported staff shortages and total staff levels were independently associated with changes in nursing home (NH) outcomes in 2020.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

A total of 8466 NHs with staffing and outcome data.

METHODS

This study used NH COVID-19 Public File (2020), Nursing Home Compare (2019-2020), and Payroll-Based Journal data (2019-2020). Outcome measures included the percentage of long-stay residents in a facility with declines in activities in daily living (ADLs), decreases in mobility, weight loss, and pressure ulcers in 2020 Q2, 2020 Q3, and 2020 Q4. Independent variables were whether NHs reported any shortage of aides or licensed nurses and total staff hours per resident day (HPRD). Separate 2-level (NH, state) Hierarchical Generalized Linear Mixed models examined the association of facility-reported shortages and staff hours with key NH resident outcomes, controlling for NH characteristics and COVID-19 infections.

RESULTS

The weekly percentage of NHs reporting any staff shortage averaged 20%. Total staff HPRD increased slightly from 3.7 in 2019 to 3.8 in 2020. Health outcomes were stable during 2019 and 2020 Q1 but worsened substantially starting in 2020 Q2. For example, the percentage of residents with mobility loss increased from 16.2% in 2020 Q1 to 27.9% in 2020 Q4. Facility-reported staff shortages were associated with an increase in the proportion of residents with an ADL decline (0.54 percentage points), mobility loss (0.80 percentage points), weight loss (0.22 percentage points), and pressure ulcers (0.22 percentage points) (all P < .01). Total staff HPRD was not associated with changes in any outcomes (all P > .05).

CONCLUSIONS AND IMPLICATIONS

NHs reported worsened health outcomes among long-stay residents in 2020, with worse outcomes found among facilities that reported staff shortages but not among those with lower total staff levels. Facility-reported shortages provide important quality information during the COVID-19 pandemic.

Experiences of Non-Family Paid Helpers Providing Palliative Care to Stroke Patients: The Toll of Professional Informal Caregiving in a Job Lacking Recognition

Background: Employing non-family paid helpers has become a prevalent practice across North America, Europe, and Asia, which families adopt to alleviate the stroke care burden, allowing family to take a break from their obligations and perform other social activities. However, paid helpers' experiences of providing palliative care to stroke patients are under-explored. This study aimed to explore the caregiving experiences of non-family paid helpers providing palliative care to stroke patients. Method: A qualitative descriptive study was undertaken using purposive sampling and semi-structured individual in-depth interviews. Thematic analysis was used for data analysis. Results: Seventeen participants (mean age: 51.23 years) were included, predominantly being female (88%), and their caregiving experiences with patients ranged from four to 26 years. Participants shared that monetary compensation offset the exhaustion, familial and health sacrifices of palliative caregiving. They emphasized emotional self-management through accepting and coping or avoiding and distancing, and appreciated rewarding appraisals from stroke patients and family members. They also expressed a lack of recognition from the public, being invisible to the healthcare system/professionals, and insecurity in employment rights. Conclusions: Findings support the need for governmental initiatives to subsidize families in employing helpers to provide palliative care. Helpers perceived monetary compensation and a reciprocal caregiving relationship as the primary motives for providing care. Public recognition of this role as a helper in caregiving, contractual employment rights, and being recognized by the healthcare system and healthcare professionals are considerations in promoting quality care and alleviating a health care burden. The findings may contribute to further understanding of the experiences of non-family paid helpers in a job lacking recognition when delivering palliative care in a hospital for stroke patients. Evidence-based interventions that enhance reciprocity and recognition should be considered as part of the global initiatives to support paid helpers in palliative care.

Flanders Nursing Home (FLANH) project: Protocol of a multicenter longitudinal observational study on staffing, work environment, rationing of care, and resident and care worker outcomes

BACKGROUND

While the demand for high quality of care in nursing homes is rising, it is becoming increasingly difficult to recruit and retain qualified care workers. To date, evidence regarding key organizational factors such as staffing, work environment, and rationing of care, and their relationship with resident and care worker outcomes in nursing homes is still scarce. Therefore, the Flanders Nursing Home (FLANH) project aims to comprehensively examine these relationships in order to contribute to the scientific knowledge base needed for optimal quality of care and workforce planning in nursing homes.

METHODS

FLANH is a multicenter longitudinal observational study in Flemish nursing homes based on survey and registry data that will be collected in 2023 and 2025. Nursing home characteristics and staffing variables will be collected through a management survey, while work environment variables, rationing of care, and care worker characteristics and outcomes will be collected through a care worker survey. Resident characteristics and outcomes will be retrieved from the Belgian Resident Assessment Instrument for long-Term Care Facilities (BelRAI LTCF) database. Multilevel regression analyses will be applied to examine the relationships between staffing variables, work environment variables, and rationing of care and resident and care worker outcomes.

CONCLUSION

This study will contribute to a comprehensive understanding of the nursing home context and the interrelated factors influencing residents and care workers. The findings will inform the decision-making of nursing home managers and policymakers, and evidence-based strategies to optimize quality of care and workforce planning in nursing homes.

Nursing-sensitive quality indicators for quality improvement in Norwegian nursing homes - a modified Delphi study

BACKGROUND

Use of nursing-sensitive quality indicators (QIs) is one way to monitor the quality of care in nursing homes (NHs). The aim of this study was to develop a consensus list of nursing-sensitive QIs for Norwegian NHs.

METHODS

A narrative literature review followed by a non-in-person, two-round, six-step modified Delphi survey was conducted. A five-member project group was established to draw up a list of nursing-sensitive QIs from a preliminary list of 24 QIs selected from Minimum Data Set (2.0) (MDS) and the international Resident Assessment Instrument for Long-Term Care Facilities (interRAI LTCF). We included scientific experts (researchers), clinical experts (healthcare professionals in NHs), and experts of experience (next-of-kin of NH residents). The experts rated nursing-sensitive QIs in two rounds on a seven-point Likert scale. Consensus was based on median value and level of dispersion. Analyses were conducted for four groups: 1) all experts, 2) scientific experts, 3) clinical experts, and 4) experts of experience.

RESULTS

The project group drew up a list of 20 nursing-sensitive QIs. Nineteen QIs were selected from MDS/interRAI LTCF and one ('systematic medication review') from the Norwegian quality assessment system IPLOS ('Statistics linked to individual needs of care'). In the first and second Delphi round, 44 experts (13 researchers, 17 healthcare professionals, 14 next-of-kin) and 28 experts (8 researchers, 10 healthcare professionals, 10 next-of-kin) participated, respectively. The final consensus list consisted of 16 nursing-sensitive QIs, which were ranked in this order by the 'all expert group': 1) systematic medication review, 2) pressure ulcers, 3) behavioral symptoms, 4) pain, 5) dehydration, 6) oral/dental health problems, 7) urinary tract infection, 8) fecal impaction, 9) depression, 10) use of aids that inhibit freedom of movement, 11) participation in activities of interest, 12) participation in social activities, 13) decline in activities of daily living, 14) weight loss, 15) falls, and 16) hearing loss without the use of hearing aids.

CONCLUSIONS

Multidisciplinary experts were able to reach consensus on 16 nursing-sensitive QIs. The results from this study can be used to implement QIs in Norwegian NHs, which can improve the quality of care.

Winter Storm Uri Reduced Availability of Daily Direct-Care Nurse Staff in Texas Nursing Homes

We examined the effect of Winter Storm Uri on daily direct-care nurse staffing levels in 1,173 Texas nursing homes (NHs) from February 13th to 19th, 2021. We used data from Payroll-Based Journaling and the Care Compare website. Linear mixed effects models were used to estimate the linear and non-linear change in staffing. During Winter Storm Uri, Texas NHs experienced a linear decrease in daily staffing levels with subsequent non-linear increase for registered nurses (RNs; p < .001) and certified nursing assistants (CNAs; p < .001), and staffing increased linearly for licensed practical nurses (LPNs; p < .001). Compared to 1 week before the storm, Texas NHs reported lower staffing levels across all three types of staff, but most dramatically among LPNs and CNAs. In supplemental analyses, urban and lower quality NHs fared slightly poorer than rural and higher-quality NHs. Winter storms pose a particular challenge to NHs and their ability to maintain direct-care nurse staffing levels.

Nurse Staffing and Veteran Outcomes in the Veterans Health Administration's Community Living Centers

BACKGROUND

The demand for nursing care is rising in the long-term care setting. Nurse staffing is a crucial measure linked to health care quality measure outcomes.

PURPOSE

To assess for associations between nursing hours per patient day (NHPPD) and outcome measures in the Veterans Health Administration Community Living Centers.

METHODS

A retrospective data review of NHPPD and quality measures for 134 community living centers was conducted. Linear regression was used to assess for linear associations between average total NHPPD and 6 quality measures.

RESULTS

A significant linear association was found between average total NHPPD and falls with major injury ( P = .02) and help with activities of daily living ( P = .01). No associations were found between nurse staffing and 4 other quality measures.

CONCLUSIONS

This study adds to the body of literature regarding the impact of nurse staffing on quality measures.

Perceived Work Environment, Educational Status, Staffing Levels, and Work Outcomes in Long-Term Care Settings During COVID-19

OBJECTIVES

Coronavirus disease (COVID-19) has severely affected older residents in long-term care (LTC) settings. However, care workers' perceptions of their work environment and potential impact on their work outcomes during the pandemic is not well known. This study examined associations between care staff's perceived work environment, educational status, and facility staffing levels and work outcomes of care staff in LTC settings during the COVID-19 pandemic.

DESIGN

This study employed a cross-sectional, observational, correlational design.

SETTING AND PARTICIPANTS

A total of 207 care staff were conveniently recruited from 30 LTC settings in South Korea.

METHODS

The perceived work environment, educational status of care staff, and facility staffing levels (ie, beds-to-registered nurse [RN] and beds-to-nursing assistant [NA] or care worker ratios), as well as their work outcomes (ie, general and COVID-19 specific outcomes) were collected using questionnaires. Multivariable binary logistic regressions were conducted, controlling for the characteristics of care staff (ie, age, sex, occupation, and career length) and facilities (ie, location, bed size, ownership, and residents' disease and care profiles).

RESULTS

Approximately 45% of the participants were either NAs or care workers, and 38% were RNs. More than half (53.14%) perceived their work environment to be good. LTC staff who perceived their work environment to be poor were more likely to be dissatisfied with their work [odds ratio (OR) 20.88), experience high burnout (OR 8.63), intend to leave the facility within a year (OR 5.00), and experience increased overtime work (OR 3.58) and work-life imbalance (OR 1.93) due to COVID-19.

CONCLUSIONS AND IMPLICATIONS

LTC work environments should be improved and government-led initiatives for ensuring such improvements should be implemented to enable a better response to future public health crises and maintain the quality of care for and safety of residents in LTC settings.

The work status of nurses in long-term care institutions in elderly care: A qualitative descriptive study

AIM

To understand the work status of nurses in long-term care institutions in China for elderly care to provide a reference for further formulating management strategies and promoting the development of long-term care teams.

METHODS

Using qualitative descriptive research methods, 31 nurses from three long-term care institutions were selected through purposive sampling for in-depth interviews, and a three-week participatory observation was conducted on the daily work of nurses in the above three long-term care institutions. Content analysis was used to analyse data.

RESULTS

In our sample, nurses in long-term care institutions had insufficient manpower, generally had low academic qualifications, and lacked professional ability. Their work enthusiasm and initiative need to be further improved. Long-term care nurses were moderately paid, and their salary satisfaction was lower than in other trades. At the same time, the social understanding of the long-term care industry was insufficient, and the social identity of nurses in long-term care institutions was low.

CONCLUSION

The development of long-term care requires the joint efforts of nurses, medical institutions, and society. By improving the system, cultivating talents and building a harmonious atmosphere, we aim to enhance the work enthusiasm of long-term care nurses and promote the stable and orderly development of the long-term care team.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurses in long-term care institutions are at the core of the ageing age and play a vital role in coping with the ageing problem, meeting long-term care needs, improving the quality of life of old people and reducing the cost of long-term care. The training and management of nurses in long-term care institutions and the construction of the entire long-term care system should be based on China's national conditions and actual needs.

Why do workers leave geriatric care, and do they come back? A timing of events study

BACKGROUND

In many industrialized countries, demographic change is accompanied by increasing demand for geriatric care workers, which in turn intensifies the need to retain them or to attract them back after leaving. Although much is known about the intention of workers to leave, little is known about how many of them actually do leave and return to geriatric care at a later stage in a comprehensive framework.

OBJECTIVE

To examine and explain how many workers withdraw from geriatric care, take up other occupations, and return to geriatric care at a later stage in their careers, and the reasons behind this.

DESIGN

This study used administrative daily data that cover all workers in Germany who started working in geriatric care in the period 1996 to 2018 and observed their employment biographies for a maximum of 26 years.

METHODS

Kaplan-Meier survival analysis and parametric regression survival-time analysis were used to estimate the survival rates and to estimate individual, workplace and regional determinants of leaving and returning to geriatric care.

RESULTS

Workers in geriatric care were more likely to leave the profession than other workers, two thirds withdrew within five years of first taking up work in geriatric care. If they remained in employment, they generally chose an occupation related to geriatric care. Half of the leavers returned to geriatric care again within eight years. Individual and workplace-related factors, such as age and remuneration, are statistically significant predictors of leaving and returning.

CONCLUSIONS

The findings emphasize how important it is for organizations to keep in touch with geriatric care workers leaving their job, since a substantial share of them returns again.

Administrative burden in Swiss nursing homes and its association with care workers' outcomes-a multicenter cross-sectional study

BACKGROUND

Care workers in nursing homes often perform tasks that are rather related to organizational or management activities than 'direct patient care'. 'Indirect care activities', such as documentation or other administrative tasks are often considered by care workers as a burden, as they increase overall workload and keep them away from caring for residents. So far, there is little investigation into what kind of administrative tasks are being performed in nursing homes, by which type of care workers, and to which extent, nor how administrative burden is associated with care workers' outcomes.

PURPOSE

The objective of this study was to describe care workers' administrative burden in Swiss nursing homes and to explore the association with four care worker outcomes (i.e., job dissatisfaction, emotional exhaustion, intention to leave the current job and the profession).

METHODS

This multicenter cross-sectional study used survey data from the Swiss Nursing Homes Human Resources Project 2018. It included a convenience sample of 118 nursing homes and 2'207 care workers (i.e., registered nurses, licensed practical nurses) from Switzerland's German- and French-speaking regions. Care workers completed questionnaires assessing the administrative tasks and burden, staffing and resource adequacy, leadership ability, implicit rationing of nursing care and care worker characteristics and outcomes. For the analysis, we applied generalized linear mixed models, including individual-level nurse survey data and data on unit and facility characteristics.

RESULTS

Overall, 73.9% (n = 1'561) of care workers felt strongly or rather strongly burdened, with one third (36.6%, n = 787) reporting to spend 2 h or more during a "normal" day performing administrative tasks. Ratings for administrative burden ranged from 42.6% (n = 884; ordering supplies and managing stocks) to 75.3% (n = 1'621; filling out the resident's health record). One out of four care workers (25.5%, n = 561) intended to leave the profession, whereby care workers reporting higher administrative task burden (OR = 1.24; 95%CI: 1.02-1.50) were more likely to intend to leave the profession.

CONCLUSION

This study provides first insights on care workers' administrative burden in nursing homes. By limiting care workers' burdensome administrative tasks and/or shifting such tasks from higher to lower educated care workers or administrative personnel when appropriate, nursing home managers could reduce care workers' workload and improve their job satisfaction and retention in the profession.

Long-Term Care Resident Health and Quality of Care During the COVID-19 Pandemic: A Synthesis Analysis of Canadian Institute for Health Information Data Tables

Objective

Long-term care (LTC) homes ("nursing homes") were challenged during the first year of the COVID-19 pandemic in Canada. The objective of this study was to measure the impact of the COVID-19 pandemic on resident admission and discharge rates, resident health attributes, treatments, and quality of care.

Design

Synthesis analysis of "Quick Stats" standardized data table reports published yearly by the Canadian Institute for Health Information. These reports are a pan-Canadian scorecard of LTC services rendered, resident health characteristics, and quality indicator performance.

Setting and participants

LTC home residents in Alberta, British Columbia, Manitoba, and Ontario, Canada that were assessed with the interRAI Minimum Data Set 2.0 comprehensive health assessment in fiscal years 2018/2019, 2019/2020 (pre-pandemic period), and 2020/2021 (pandemic period).

Methods

Risk ratio statistics were calculated to compare admission and discharge rates, validated interRAI clinical summary scale scores, medication, therapy and treatment provision, and seventeen risk-adjusted quality indicator rates from the pandemic period relative to prior fiscal years.

Results

Risk of dying in the LTC home was greater in all provinces (risk ratio [RR] range 1.06-1.18) during the pandemic. Quality of care worsened substantially on 6 of 17 quality indicators in British Columbia and Ontario, and 2 quality indicators in Manitoba and Alberta. The only quality indicator where performance worsened during the pandemic in all provinces was the percentage of residents that received antipsychotic medications without a diagnosis of psychosis (RR range 1.01-1.09).

Conclusions and implications

The COVID-19 pandemic has unveiled numerous areas to strengthen LTC and ensure that resident's physical, social, and psychological needs are addressed during public health emergencies. Except an increase in potentially inappropriate antipsychotic use, this provincial-level analysis indicates that most aspects of resident care were maintained during the first year of the COVID-19 pandemic.

Injury-related emergency department use among assisted living residents with Alzheimer's disease and related dementias

BACKGROUND

Injuries are a leading cause of emergency department (ED) visits among older adults, and individuals with Alzheimer's disease and related dementias (ADRD) may be at particular risk. We compared injury-related ED use among assisted living (AL) residents with and without ADRD and assessed differences in the risk of injury-related ED visits among individuals with ADRD residing in ALs with memory care designation versus general AL.

METHODS

Using Medicare claims, we identified a cohort of fee-for-service beneficiaries who lived in AL in 2018 and resided in one of 20 states with site-specific information on memory care designation (n = 116,754). Outcomes included all injury-related ED visits and injury-related ED visits resulting in hospitalization in the calendar year 2018. We fit multilevel models of the association between ADRD and outcomes, adjusting for resident demographic characteristics and chronic conditions, license type characteristics, and AL characteristics, with random intercepts at the AL and license type levels. Among residents with ADRD, we examined whether memory care licensure was associated with injury-related ED visits.

RESULTS

The adjusted risk of injury-related ED use during the year was 20.1% (95% CI: 19.6%, 20.6%) for residents with ADRD compared to 16.1% for residents without ADRD (95% CI: 15.7%, 16.5%; p < 0.001). The adjusted risk of injury-related ED use ending in hospitalization was 4.9% (95% CI: 4.6%, 5.1%) for AL residents with ADRD and 3.9% for residents without ADRD (95% CI: 3.8%, 4.1%; p < 0.001). There were no significant differences in injury-related ED visits between residents with ADRD in ALs with memory care designation and residents in general AL.

CONCLUSIONS

Injury-related ED visits are common among AL residents with ADRD and residents in memory care, but residents in memory care AL experienced similar risks of injury as those in general AL. Further research should identify modifiable factors that can prevent injury among AL residents with ADRD.

Paid caregivers' experiences of falls prevention and care in China's senior care facilities: A phenomenological study

Background

In China, as population aging accelerates, senior care facilities have gradually become a mainstream option. According to the World Health Organization (WHO), the annual rate of falls has increased from 30 to 50% in senior care facilities. A study found that older adults who live in senior care facilities are three times more likely to fall than those who live in the community. The quality of care is highly related to the occurrence of falls. Therefore, exploring paid caregivers' experiences is very important to prevent falls in senior care facilities.

Objective

The aim of this study was to explore paid caregivers' experiences of fall prevention and care in China's senior care facilities. Furthermore, we discussed the situation and provided suggestions.

Design

This is a phenomenological study using face-to-face, in-depth, semi-structured interviews.

Setting

The study was conducted at four senior care facilities in Changsha, Hunan, China.

Participants

Fourteen paid caregivers in four senior care facilities, including nursing assistants and senior nurses, participated in this study.

Methods

A purposive sample method was used to select 14 nursing assistants and senior nurses from four different senior care facilities in Changsha from March to April 2022. Every participant individually completed a face-to-face, in-depth, semi-structured interview. Based on the phenomenological research methodology, the thematic analysis method and the Colaizzi analysis method were used for data analysis and theme extraction.

Results

Based on interview data, a total of seven themes were distilled: (1) paid caregivers' professional requirements; (2) paid caregivers' attitude toward falls; (3) paid caregivers' fall training and education; (4) paid caregivers' knowledge about falls; (5) paid caregivers' fall risk assessment; (6) paid caregivers' fall prevention; and (7) paid caregivers' fall treatment.

Conclusion

In China's senior care facilities, paid caregivers to need to be responsible and pay appropriate attention to older adults. First, senior nurses and nursing assistants need to enhance communication and cooperation. Second, they must learn about deficiencies in fall risk assessment and try their best to improve their capability. Third, they must adopt appropriate education methods to improve fall prevention capability. Finally, the protection of privacy should be taken seriously.

Effects of Nurse Staffing on Resident Outcomes in Nursing Homes: A Systematic Review

OBJECTIVES

To evaluate the evidence on effects of nurse staffing in nursing homes on resident outcomes.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Studies evaluating the effects of nurse staffing levels, total staffing, or skill mix on pressure ulcers, nursing home associated infections, and pain outcomes for adult residents in US nursing homes.

METHODS

We searched MEDLINE, Embase, CINAHL, and the Cochrane Database for English-language articles published between January 2000 and May 2021. We also searched for gray literature and sought expert referrals. Two reviewers participated in determination of eligibility, assessment of methodological quality, and abstraction of data. Abstracted data included study design; setting and population characteristics; and resident outcomes. We rated overall certainty of evidence (very low, low, moderate, and high) for each outcome using GRADE.

RESULTS

Of 9152 unique citations, 378 articles underwent full-text review. We identified 22 eligible studies that addressed pressure ulcers (k = 15), COVID-19 cases and/or mortality (k = 4), other infections (k = 8), and moderate-severe pain among residents (k = 7); some examined multiple outcomes. Most studies (k = 17) were rated moderate or high quality. All studies were observational. Overall, registered nurse (RN) staffing was probably associated with fewer pressure ulcers (moderate certainty) and possibly fewer COVID-19 infections/mortality (low certainty), other infections (low certainty) and lower rates of moderate-severe pain (low certainty). Higher skill mix was probably associated with fewer pressure ulcers, higher resident COVID-19 infections, fewer other infections, and lower rates of moderate-severe pain (low certainty for all outcomes).

CONCLUSIONS AND IMPLICATIONS

Higher RN staffing and skill mix may be associated with better nursing home resident outcomes, while results were mixed for total staffing. Increasing RN staffing levels and skill mix are one of a variety of approaches to improve nursing home care.

Role of Pimavanserin Treatment-Continuity on Discharge From Long-term Care: Assessing the Quality of Antipsychotic Medication Review

Objective: To investigate the role of (1) antipsychotic medication review (AP-MR) documentation quality of Minimum Data Set 3.0 (MDS) surveys, and (2) treatment-continuity on discharge-to-community and clinical outcomes among long-term care (LTC) residents treated with pimavanserin. Design, Setting, and Participants: A retrospective cohort analysis of Parts A, B, and D claims from Medicare 100% sample merged with MDS data from June 2016 through December 2018 was conducted. Residents with more than 100-day LTC stay and 1 pimavanserin prescription or more with completed antipsychotic-use MDS question were selected. AP-MR documentation quality (ie, gradual dose reduction [GDR] attempts, clinical contraindication to GDR), discharge-to-community, and clinical outcomes (eg, falls, fractures) were obtained from MDS. Treatment-continuity was assessed from Part D claims. Data Analysis: Descriptive statistics (frequencies, proportions, Chi-square tests, and means) and adjusted logistic regressions (ORs with 95% CIs reported association between pimavanserin treatment-continuity and discharge-to-community. Results: Of 4,021 eligible residents, 29% (n = 1,182) attempted a GDR per AP-MR MDS documentation. Approximately 41% (n = 1,665) had documentation showing GDR was clinically contraindicated, yet 39% (n = 645) still attempted GDR. While overall discharge-to-community rates were low, it was significantly higher (P < 0.05) among LTC residents continuing (14.94%; n = 380/2,546) versus discontinuing (11.84%; n = 171/1,444) pimavanserin. OR for treatment-continuity was 1.96, 95% CI 1.50-2.55. Residents continuing pimavanserin had lower incidents of falls (2.8% vs 9.4%), hip fractures (0.29% vs 0.69%), and pelvic/femur fractures (0% vs 0.92%) versus those residents who discontinued it. Conclusions: Among LTC-stay residents, high discordance between GDR rates and AP-MR MDS documentation quality was observed. Pimvanserin treatment-continuity showed greater likelihood of discharge-to-community; continued documentation training can ensure appropriate antipsychotic use with a balanced benefit:risk profile.

Preventing healthcare-related infections among older adults: a focus on cross-transmission of antibiotic-resistant bacteria

INTRODUCTION

Older individuals (i.e. age ≥65 years) are at increased risk for development of infections including those due to antimicrobial-resistant bacteria, and transmission may occur between institutional and community settings.

AREAS COVERED

This article reviews infections in older individuals with a specific focus on healthcare-related and antimicrobial resistant infections. A structured narrative review was performed to identify articles published in English since 2010. Themes included defining the scope of the problem, establishing characteristics of older individuals that impact the burden of resistant infections, and interventions aimed at minimizing their impact.

EXPERT OPINION

Older individuals suffer a high burden of illness related to antimicrobial resistant infections. Individuals with chronic illnesses, frailty, and residents of nursing homes are at highest risk. Clinical trials have shown that antimicrobial stewardship interventions may reduce antibiotic use in nursing homes without compromising safety. Antimicrobial resistant bacteria are prevalent among nursing home residents, and bundled infection prevention and control interventions can reduce their transmission. Transmission of antimicrobial resistant bacteria occurs among older adults across hospital and institutional settings, which may further spread to the community. The burden of infections in older adults is expected to increase in the coming years and represents a healthcare and research priority.

''We usually choose safety over freedom'': results from focus groups with professional caregivers in long-term dementia care

Background

People with dementia living in nursing homes are mostly sedentary, which is a consequence of various personal, environmental and organizational factors. Until now, studies on physical activity and safety in dementia have focused on residents and caregivers from the viewpoint of (individual) care provision and health benefits. There has been little to no focus on the possible influence of group dynamics between care providers with regard to physical activity and safety. The aim of this study is to gain more insight into the viewpoints and intentions of groups of professional caregivers towards safety and physical activity and the potential influence of the group-oriented setting in long-term care on physical activity of individual residents.

Methods

A qualitative study comprising three focus group discussions including professional caregivers (n = 15) was conducted within two long-term care organizations in the Netherlands. Focus group discussions were structured using an interview guide derived from a preliminary framework, based on existing literature and complemented with clinical expertise.

Results

Seven themes could be derived from the focus group discussions that influence physical activity and safety: 1) Individual health and abilities; 2) Balancing physical activity and safety; 3) Physical restraints; 4) Group interests versus the individual interests; 5) Organization of care and physical environment; 6) Perceived responsibilities and tasks of professional caregivers and 7) Change is challenging.

Conclusions

Due to multiple influencing factors, the balance for care providers in long-term care generally tends towards safety over physical activity. Furthermore, in order to stimulate physical activity various limitations are experienced, including the organization of care, the general health of the residents and difficulty to achieve changes in daily care. Most importantly, the group interests of both the professional caregivers and the residents have a substantial influence on the incorporation of physical activity in daily care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07952-0.

Who's in the House? Staffing in Long-Term Care Homes Before and During COVID-19 Pandemic

Critical gaps exist in our knowledge on how best to provide quality person-centered care to long-term care (LTC) home residents which is closely tied to not knowing what the ideal staff is complement in the home. A survey was created on staffing in LTC homes before and during the COVID-19 pandemic to determine how the staff complement changed. Perspectives were garnered from researchers, clinicians, and policy experts in eight countries and the data provides a first approximation of staffing before and during the pandemic. Five broad categories of staff working in LTC homes were as follows: (1) those responsible for personal and support care, (2) nursing care, (3) medical care, (4) rehabilitation and recreational care, and (5) others. There is limited availability of data related to measuring staff complement in the home and those with similar roles had different titles making it difficult to compare between countries. Nevertheless, the survey results highlight that some categories of staff were either absent or deemed non-essential during the pandemic. We require standardized high-quality workforce data to design better decision-making tools for staffing and planning, which are in line with the complex care needs of the residents and prevent precarious work conditions for staff.

Factors Associated With Low and High Social Engagement Among Older Nursing Home Residents in Korea

OBJECTIVES

With the increase in older adults receiving long-term care in facilities, the level of social engagement within nursing homes is a growing concern for improving the quality of life of residents. This study seeks to assess the level of social engagement and identify the factors associated with high and low engagement among older adults in Korean nursing homes.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Data were obtained from a nationally representative sample of 1453 older residents in 92 long-term care facilities across Korea.

METHODS

Multilevel-multivariate analyses were carried out to identify individual- and institution-level risk factors of social engagement, as measured by the Revised Index of Social Engagement (RISE).

RESULTS

Three-fourths of older residents had a low level of social engagement, whereas only about 1/10th showed a high level of social engagement. Being male, having severe functional impairments, having depression, and having no supportive family relationships were risk factors for low social engagement. Conversely, a high level of social engagement was significantly associated with being female, having no impairments, and a longer length of stay. Meeting staffing requirements for personal care assistants, an institution-level factor, was negatively associated with low social engagement and positively associated with high social engagement.

CONCLUSIONS AND IMPLICATIONS

Low social engagement is very common in Korean nursing homes and is concentrated among those with poor functional and social outcomes. Future efforts to improve long-term care will need to address the various factors associated with social engagement in designing social care for nursing home residents.

Changing landscape of nursing homes serving residents with dementia and mental illnesses

OBJECTIVE

Nursing homes (NHs) are serving an increasing proportion of residents with cognitive issues (e.g., dementia) and mental health conditions. This study aims to: (1) implement unsupervised machine learning to cluster NHs based on residents' dementia and mental health conditions; (2) examine NH staffing related to the clusters; and (3) investigate the association of staffing and NH quality (measured by the number of deficiencies and deficiency scores) in each cluster.

DATA SOURCES

2009-2017 Certification and Survey Provider Enhanced Reporting (CASPER) were merged with LTCFocUS.org data on NHs in the United States.

STUDY DESIGN

Unsupervised machine learning algorithm (K-means) clustered NHs based on percent residents with dementia, depression, and serious mental illness (SMI, e.g., schizophrenia, anxiety). Panel fixed-effects regressions on deficiency outcomes with staffing-cluster interactions were conducted to examine the effects of staffing on deficiency outcomes in each cluster.

DATA EXTRACTION METHODS

We identified 110,463 NH-year observations from 14,671 unique NHs using CASPER data.

PRINCIPAL FINDINGS

Three clusters were identified: low dementia and mental illnesses (Postacute Cluster); high dementia and depression, but low SMI (Long-stay Cluster); and high dementia and mental illnesses (Cognitive-mental Cluster). From 2009 to 2017, the number of Postacute Cluster NHs increased from 3074 to 5719, while the number of Long-stay Cluster NHs decreased from 6745 to 3058. NHs in Long-stay/Cognitive-mental Clusters reported slightly lower nursing staff hours in 2017. Regressions suggested the effect of increasing staffing on reducing deficiencies is statistically similar across NH clusters. For example, 1 hour increase in registered nurse hours per resident day was associated with -0.67 (standard error [SE] = 0.11), -0.88 (SE = 0.12), and -0.97 (SE = 0.15) deficiencies in Postacute Cluster, Long-stay Cluster, and Cognitive-mental Cluster, respectively.

CONCLUSIONS

Unsupervised machine learning detected a changing landscape of NH serving residents with dementia and mental illnesses, which requires assuring staffing levels and trainings are suited to residents' needs.