A systems framework for evaluating nursing care quality in nursing homes

Perceived dilemma between protective measures and social isolation in nursing homes during the COVID-19 pandemic: a mixed methods study among Swiss nursing home directors

Background

Coronavirus pandemic (COVID-19) particularly affected older adults, with the highest risks for nursing home residents. Stringent governmental protective measures for nursing homes unintendedly led to social isolation of residents. Nursing home directors (NDs) found themselves in a dilemma between implementing protective measures and preventing the social isolation of nursing home residents.

Objectives

The objectives of this study were to describe protective measures implemented, to investigate NDs' perception of social isolation and its burden for nursing home residents due to these measures, and to explore experiences of NDs in the context of the dilemma.

Methods

Cross-sectional embedded mixed-method study carried out by an online survey between April 27 and June 09, 2022, among NDs in the German-speaking part of Switzerland. The survey consisted of 84 closed-ended and nine open-ended questions. Quantitative findings were analyzed with descriptive statistics and qualitative data were evaluated using content analysis.

Results

The survey was completed by 398 NDs (62.8% female, mean age 55 [48-58] years) out of 1'044 NDs invited.NDs were highly aware of the dilemma. The measures perceived as the most troublesome were restrictions to leave rooms, wards or the home, restrictions for visitors, and reduced group activities. NDs and their teams developed a variety of strategies to cope with the dilemma, but were burdened themselves by the dilemma.

Conclusion

As NDs were burdened themselves by the responsibility of how to deal best with the dilemma between protective measures and social isolation, supportive strategies for NDs are needed.

Social Connectedness among Long-Stay Nursing Home Residents with Alzheimer's and Dementia: Exploring Individual and Facility-Level Variation

INTRODUCTION

This study sought to explore individual and facility-level variation in social connectedness among long-stay nursing home residents with Alzheimer's or other dementias (ADRD).

METHODS

We identified 721,074 long-stay residents with ADRD using 2016 Minimum Data Set 3.0 data. Social connectedness was defined using the social connectedness index (SCI) (high: SCI = 5, lower: 0 < SCI ≤ 4). Adjusted odds ratios (aOR) provided estimates of the associations between resident-level and facility-level characteristics, and high SCI was derived from logistic models.

RESULTS

The SCI Cronbach's alpha was 0.69; 78.6% had high SCI scores. Men were less likely than women to have higher SCI scores (aOR = 0.97; 95% CI: 0.97-0.98). Increasing age was associated with higher SCI scores (e.g., aOR [85-94 vs. 40-64 years]: 1.07; 95% CI: 1.06-1.07). Those with moderate cognitive impairment (aOR: 0.87) and severe cognitive impairment (aOR: 0.85) had reduced odds of SCI = 5 relative to those with mild/intact cognitive function. Residents living in homes with special care dementia units and with higher percentage of residents with dementia had decreased odds of high social connectedness.

DISCUSSION/CONCLUSION

Understanding resident- and nursing home-level variation in social connectedness may be important for targeting interventions that reduce isolation among residents with ADRD.

Perceptions and experiences of residents and relatives of emergencies in care homes: a systematic review and metasynthesis of qualitative research

Background

the perceptions and experiences of care home residents and their families are important for understanding and improving the quality of emergency care.

Methods

we conducted a systematic review and metasynthesis to understand the perceptions and experiences of care home residents and their family members who experienced medical emergencies in a care home setting. The review protocol was registered in PROSPERO (CRD42020167018). We searched five electronic databases, MEDLINE, CINAHL, PubMed, Cochrane Library and PsycINFO, supplemented with internet searches and forward and backward citation tracking from included studies and review articles. Data were synthesised thematically following the Thomas and Harden approach. The Critical Appraisal Skills Programme qualitative checklist was used to assess the quality of studies included in this review.

Results

of the 6,140 references retrieved, 10 studies from four countries (Australia, Canada, UK and USA) were included in the review and metasynthesis. All the included studies were assessed as being of good quality. Through an iterative approach, we developed six analytical themes: (i) infrastructure and process requirements in care homes to prevent and address emergencies; (ii) the decision to transfer to hospital; (iii) experiences of transfer and hospitalisation for older patients; (iv) good communication is vital for desirable outcomes; (v) legal, regulatory and ethical concerns and (vi) trusting relationships enabled residents to feel safe.

Conclusions

the emergency care experience for care home residents can be enhanced by ensuring resources, staff capacity and processes for high quality care and trusting relationships between staff, patients and relatives, underpinned by good communication and attention to ethical practice.

Identifying Frequently Used NANDA-I Nursing Diagnoses, NOC Outcomes, NIC Interventions, and NNN Linkages for Nursing Home Residents in Korea

This study aimed to identify the terminologies of NANDA-I, NOC, NIC, and NNN linkages that have been used for nursing home (NH) residents. This study used a retrospective descriptive design. Data accrued from 57 registered nurses (RNs) in 25 Korean NHs. The RNs randomly selected one resident and assessed for applied NANDA-I, NOC, and NIC from the previous 7 days by reviewing nursing charts and records. Finally, the data of 57 residents in 25 NHs were collected. Results: We identified seven NNN linkages: risk for falls-fall prevention behavior-fall prevention; self-care deficit: bathing/hygiene-self-care: activities of daily living (ADL)-self-care assistance: bathing/hygiene; impaired memory-memory-cognitive stimulation; chronic confusion-neurological status: consciousness-medication management; chronic confusion-memory-medication management; impaired walking-mobility-exercise promotion: strength training; and impaired walking-ambulation-exercise promotion: strength training. The identified core NANDA-I, NOC, NIC, and NNN linkages for NH residents from this study provide a scope of practice of RNs working in NHs.

Resident and Institutional-Level Factors, Frailty, and Nursing Homes Residents

BACKGROUND

Frailty is a major cause of adverse health outcomes such as hospitalization, falls, disability, and morbidity among older adults; the elucidation of factors affecting frailty trends over time may facilitate the development of effective interventions.

OBJECTIVES

This study aimed to examine the trend of frailty over time (at baseline, with 6-month and 12-month follow-ups) among Chinese nursing home residents and identify associated resident- and institutional-level factors.

METHODS

This longitudinal study included 353 residents who were admitted into 27 nursing homes in Jinan, China. Frailty was defined based on the seven self-reported components of the FRAIL-NH scale, which was designed for nursing home residents. Information was gathered using scales that assessed resident-level (sociodemographic characteristics and physical, psychological, and social factors) and institutional-level characteristics (hospital affiliation, fitness sites, green space, occupancy percentage, staff-resident ratio, staff turnover rate). These data were subjected to a multilevel linear analysis.

RESULTS

Frailty was identified in 49.7% of residents at baseline and exhibited a progressively worsening trend over 1 year. Among institutional-level characteristics, the provision of fitness sites in nursing homes was a protective factor for frailty. Among resident-level characteristics, undernutrition was a significant independent risk factor and played a key role in increasing frailty over time. Other risk factors for frailty included younger age, poorer self-rated health, lower physical function, chewing difficulty, loneliness, anxiety, and being less active in leisure activities.

DISCUSSION

Frailty was highly prevalent among Chinese nursing home residents and gradually increased over time. The results of this study could be used to inform the development of interventions targeted at modifiable risk factors and shape public health policies aimed at promoting healthy aging and delaying frailty and its adverse outcomes.

Geographic Variation of Statin Use Among US Nursing Home Residents With Life-limiting Illness

BACKGROUND

Medically compromised nursing home residents continue to be prescribed statins, despite questionable benefits.

OBJECTIVE

To describe regional variation in statin use among residents with life-limiting illness.

RESEARCH DESIGN

Cross-sectional study using 2016 Minimum Data Set 3.0 assessments linked to Medicare administrative data and health service utilization area resource files.

SETTING

Nursing homes (n=14,147) within hospital referral regions (n=306) across the United States.

SUBJECTS

Long-stay residents (aged 65 y and older) with life-limiting illness (eg, serious illness, palliative care, or prognosis <6 mo to live) (n=361,170).

MEASURES

Prevalent statin use was determined by Medicare Part D claims. Stratified by age (65-75, 76 y or older), multilevel logistic models provided odds ratios with 95% confidence intervals.

RESULTS

Statin use was prevalent (age 65-75 y: 46.0%, 76 y or more: 31.6%). For both age groups, nearly all resident-level variables evaluated were associated with any and high-intensity statin use and 3 facility-level variables (ie, higher proportions of Black residents, skilled nursing care provided, and average number of medications per resident) were associated with increased odds of statin use. Although in residents aged 65-75 years, no associations were observed, residents aged 76 years or older located in hospital referral regions (HRRs) with the highest health care utilization had higher odds of statin use than those in nursing homes in HRRs with the lowest health care utilization.

CONCLUSIONS

Our findings suggest extensive geographic variation in US statin prescribing across HRRs, especially for those aged 76 years or older. This variation may reflect clinical uncertainty given the largely absent guidelines for statin use in nursing home residents.

Civil Money Penalty Enforcement Actions for Quality Deficiencies in Nursing Homes

BACKGROUND AND OBJECTIVES

Civil money penalties (CMP) are fines collected by CMS and then redistributed to states for the sole purpose of improving resident care and quality of life through reinvestment in quality improvement projects. This study examined state variation in civil money penalty enforcement actions for quality of life (QOL) and quality of care (QOC) deficiencies in nursing homes.

RESEARCH DESIGN AND METHODS

2015-2016 cross-sectional CASPER nursing home survey data obtained from the CMS QCOR database were used to explore the pattern of enforcement actions for QOL and QOC deficiencies across states. Fixed effects regression models examined relationships between state-level characteristics, quality deficiencies, and enforcement actions imposed by states.

RESULTS

State enforcement actions resulting in a CMP were more likely for QOC deficiencies (M = 0.143, SD = 0.097) than for QOL deficiencies (M = 0.070, SD = 0.056) and states exhibited variability in imposing enforcement actions. The presence of severe QOC deficiencies resulting in actual resident harm contributed to CMP enforcement actions for both QOL and QOC deficiencies. States with primarily for-profit status providers had more enforcement actions.

DISCUSSION AND IMPLICATIONS

The variability noted in state enforcement for quality deficiencies actions parallels inconsistencies in state regulatory oversight of nursing homes.

Quality Concerns in Nursing Homes That Serve Large Proportions of Residents With Serious Mental Illness

Background and Objectives

Nursing homes (NHs) are serving greater proportions of residents with serious mental illness (SMI), and it is unclear whether this affects NH quality. We analyze the highest and lowest quartiles of NHs based on the proportion of residents with SMI and compare these NHs on facility characteristics, staffing, and quality stars.

Research Design and Methods

National Certification and Survey Provider Enhanced Reports data were merged with NH Compare data for all freestanding certified NHs in the continental United States in 2016 (N = 14,460). NHs were categorized into “low-SMI” and “high-SMI” facilities using the lowest and highest quartiles, respectively, of the proportion of residents in the NH with SMI. Bivariate analyses and logistic models were used to examine differences in organizational structure, payer mix, resident characteristics, and staffing levels associated with high-SMI NHs. Linear models examined differences in quality stars.

Results

High-SMI facilities were found to report lower direct-care staffing hours, have a greater Medicaid-paying resident census, were more likely to be for-profit, and scored lower on all NH Compare star ratings in comparison to all other NHs.

Discussion and Implications

As the SMI population in NHs continues to grow, a large number of residents have concentrated in a few NHs. These are uniquely different from typical NHs in terms of facility characteristics, staffing, and care practices. While further research is needed to understand the implications of these trends, public policymakers and NH providers need to be aware of this population’s unique—and potentially unmet—needs.

Resident and facility characteristics associated with care-need level deterioration in long-term care welfare facilities in Japan

AIM

To determine the resident and facility characteristics associated with residents' care-need level deterioration in long-term care welfare facilities in Japan.

METHODS

A nationally representative sample of 358 886 residents who lived in 3774 long-term care welfare facilities for at least 1 year from October 2012 was obtained from long-term care insurance claims data. Facility characteristics were linked with a survey of institutions and establishments for long-term care in 2012. We used a multilevel logistic regression according to the inclusion and exclusion of lost to follow-up to define the resident and facility characteristics associated with resident care-need level deteriorations (lost to follow-up: the majority were hospitalized residents or had died; were treated as deterioration in the including loss to follow-up model).

RESULTS

Adjusting for the covariates, at the resident level, older age and lower care-need level at baseline were more likely to show deterioration in the care-need level. At the facility level, metropolitan facilities, unit model (all private room settings) and mixed-model facilities (partly private room settings) were less likely to experience care-need level deterioration. A higher proportion of registered nurses among all nurses was negatively related to care-need level deterioration only in the model including lost to follow-up. A higher proportion of registered dietitians among all dietitians and the facilities in business for fewer years were negatively associated with care-need level deterioration only in the model excluding lost to follow-up.

CONCLUSIONS

The present study could help identify residents who are at risk of care-need level deterioration, and could contribute to improvements in provider quality performance and enhance competence in the market. Geriatr Gerontol Int 2018; 18: 758-766.

Who Hires Social Workers? Structural and Contextual Determinants of Social Service Staffing in Nursing Homes

Although nurse staffing has been extensively studied within nursing homes (NHs), social services has received less attention. The study describes how social service departments are organized in NHs and examines the structural characteristics of NHs and other macro-focused contextual factors that explain differences in social service staffing patterns using longitudinal national data (Certification and Survey Provider Enhanced Reports, 2009-2012). NHs have three patterns of staffing for social services, using qualified social workers (QSWs); paraprofessional social service staff; and interprofessional teams, consisting of both QSWs and paraprofessionals. Although most NHs employ a QSW (89 percent), nearly half provide social services through interprofessional teams, and 11 percent rely exclusively on paraprofessionals. Along with state and federal regulations that depend on facility size, other contextual and structural factors within NHs also influence staffing. NHs most likely to hire QSWs are large facilities in urban areas within a health care complex, owned by nonprofit organizations, with more payer mixes associated with more profitable reimbursement. QSWs are least likely to be hired in small facilities in rural areas. The influence of policy in supporting the professionalization of social service staff and the need for QSWs with expertise in gerontology, especially in rural NHs, are discussed.

An Exploration of Nursing Home Organizational Processes

The purpose of this study is to explore the relationship between nursing home staffs' perceptions of organizational processes (communication, teamwork, and leadership) with characteristics (turnover, tenure, and educational preparation) of the nursing home administrator (NHA) and director of nursing (DON). NHAs and DONs rate communication, teamwork, and leadership significantly higher than direct care staff do (registered nurses, licensed practical nurses, certified nurse aides [CNAs]). CNAs have the lowest ratings of communication and teamwork. Turnover of the NHA and DON is significantly and negatively associated with communication and teamwork. Two thirds of DONs surveyed hold less than a baccalaureate degree; this does not influence staffs' ratings of communication, teamwork, and leadership. Findings from this study highlight the need to explore differences in perceptions between administrative and direct care staff and how these may or may not influence staff development and quality improvement activities in nursing homes.

Communication with Residents and Families in Nursing Homes at the End of Life

Communication with residents and their families is important to ensure that the end-of-life experience is in accordance with resident's wishes. A secondary analysis was conducted to determine: (a) who should communicate with the resident/family about death and dying; (b) when communication should occur around death and dying, obtaining a "DNR" order, and obtaining a hospice referral; and (c) what differences exist in communication about death and dying between Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and unlicensed staff. Greater than 90% of staff (N=2,191) reported that the physician or social worker should communicate about death and dying with residents/families, but only 53% thought that direct care staff should talk with them. Weighted scores for "When communication should occur about death and dying and obtaining a 'DNR' Order" revealed significantly (p < .01) lower scores for unlicensed staff than RNs and LPNS (i.e., licensed staff), indicating that licensed staff were more likely to initiate conversations on admission or at the care-planning meeting, or when the resident's family requested it. No differences were found between staff on communication about obtaining a hospice referral. The identified gaps in perception about who should be communicating can assist in developing appropriate interventions that need future testing. The potential for training regarding communication strategies and techniques could lead to higher satisfaction with end-of-life care for residents and their families.

The effects of the Green House nursing home model on ADL function trajectory: A retrospective longitudinal study

BACKGROUND

Growing attention in the past few decades has focused on improving care quality and quality of life for nursing home residents. Many traditional nursing homes have attempted to transform themselves to become more homelike emphasizing individualized care. This trend is referred to as nursing home culture change in the U.S. A promising culture change nursing home model, the Green House nursing home model, has shown positive psychological outcomes. However, little is known about whether the Green House nursing home model has positive effects on physical function compared to traditional nursing homes.

OBJECTIVES

To examine the longitudinal effects of the Green House nursing home model by comparing change patterns of activities of daily living function over time between Green House home residents and traditional nursing home residents.

DESIGN

A retrospective longitudinal study.

SETTINGS

Four Green House organizations (nine Green House units and four traditional units).

PARTICIPANTS

A total of 242 residents (93 Green House residents and 149 traditional home residents) who had stayed in the nursing home at least 6 months from admission.

METHODS

The outcome was activities of daily living function, and the main independent variable was the facility type in which the resident stayed: a Green House or traditional unit. Age, gender, comorbidity score, cognitive function, and depressive symptoms at baseline were controlled. All of these measures were from a minimum dataset. Growth curve modeling and growth mixture modeling were employed in this study for longitudinal analyses.

RESULTS

The mean activities of daily living function showed deterioration over time, and the rates of deterioration between Green House and traditional home residents were not different over time. Four different activities of daily living function trajectories were identified for 18 months, but there was no statistical difference in the likelihood of being in one of the four trajectory classes between the two groups.

CONCLUSIONS

Although Green House nursing homes are considered to represent an innovative model changing the nursing home environment into more person-centered, this study did not demonstrate significant differences in activities of daily living function changes for residents in the Green House nursing homes compared to traditional nursing homes. Given that the Green House model continues to evolve as it is being implemented and variations within and across Green House homes are identified, large-scale longitudinal studies are needed to provide further relevant information on the effects of the Green House model.

An examination of quality of care in Norwegian nursing homes - a change to more activities?

BACKGROUND

Studies on Norwegian nursing homes have shown that the general care is at a relatively high level, while the level of physical and social activities is relatively low. As a response to these findings, the Norwegian government has stressed the importance of activities in various white papers and circulars and, in recent years, has launched several campaigns specifically aimed at increasing the level of activities.

AIM

The aim of the study was to examine the following: (i) how the government has succeeded in increasing the level of physical and social activities in Norwegian nursing homes; (ii) how the level of activities compares to the general care; and (iii) how the level of activities and the general care are influenced by the following facility characteristics: residents' mobility level, total staffing levels, ratio of RNs, ratio of unlicensed staff and ward size.

METHOD

A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data.

RESULTS

On a scale ranging from 1 to 7, the staff members assess the activity dimension to be 4.31 and the general care dimension to be 5.66. The activity dimension was significantly negatively correlated with the ratio of unlicensed staff, the ratio of Registered Nurses and the residents' mobility level, while the general care dimension was significantly negatively correlated with the ratio of unlicensed staff.

CONCLUSION

The study shows that the level of physical and social activities offered to the residents is relatively low, while the general care level is significantly higher, in line with earlier studies. Consequently, the government has not succeeded with its current policy to increase the level of activities in nursing homes. The relationship between the two quality dimensions and the explanatory variables shows that nursing home quality is a complicated phenomenon.

Do Racial/Ethnic Disparities in Quality and Patient Experience within Medicare Plans Generalize across Measures and Racial/Ethnic Groups?

OBJECTIVE

To examine how similar racial/ethnic disparities in clinical quality (Healthcare Effectiveness Data and Information Set [HEDIS]) and patient experience (Consumer Assessment of Healthcare Providers and Systems [CAHPS]) measures are for different measures within Medicare Advantage (MA) plans.

DATA SOURCES/STUDY SETTING

5.7 million/492,495 MA beneficiaries with 2008-2009 HEDIS/CAHPS data.

STUDY DESIGN

Binomial (HEDIS) and linear (CAHPS) hierarchical mixed models generated contract estimates for HEDIS/CAHPS measures for Hispanics, blacks, Asian-Pacific Islanders, and whites. We examine the correlation of within-plan disparities for HEDIS and CAHPS measures across measures.

PRINCIPAL FINDINGS

Plans with disparities for a given minority group (vs. whites) for a particular measure have a moderate tendency for similar disparities for other measures of the same type (mean r = 0.51/.21 and 53/34 percent positive and statistically significant for CAHPS/HEDIS). This pattern holds to a lesser extent for correlations of CAHPS disparities and HEDIS disparities (mean r = 0.05/0.14/0.23 and 4.4/5.6/4.4 percent) positive and statistically significant for blacks/Hispanics/API.

CONCLUSIONS

Similarities in CAHPS and HEDIS disparities across measures might reflect common structural factors, such as language services or provider incentives, affecting several measures simultaneously. Health plan structural changes might reduce disparities across multiple measures.

The Omaha System: a systematic review of the recent literature

BACKGROUND

The Omaha System (OS) is one of the oldest of the American Nurses Association recognized standardized terminologies describing and measuring the impact of healthcare services. This systematic review presents the state of science on the use of the OS in practice, research, and education.

AIMS

(1) To identify, describe and evaluate the publications on the OS between 2004 and 2011, (2) to identify major trends in the use of the OS in research, practice, and education, and (3) to suggest areas for future research.

METHODS

Systematic search in the largest online healthcare databases (PUBMED, CINAHL, Scopus, PsycINFO, Ovid) from 2004 to 2011. Methodological quality of the reviewed research studies was evaluated.

RESULTS

56 publications on the OS were identified and analyzed. The methodological quality of the reviewed research studies was relatively high. Over time, publications' focus shifted from describing clients' problems toward outcomes research. There was an increasing application of advanced statistical methods and a significant portion of authors focused on classification and interoperability research. There was an increasing body of international literature on the OS. Little research focused on the theoretical aspects of the OS, the effective use of the OS in education, or cultural adaptations of the OS outside the USA.

CONCLUSIONS

The OS has a high potential to provide meaningful and high quality information about complex healthcare services. Further research on the OS should focus on its applicability in healthcare education, theoretical underpinnings and international validity. Researchers analyzing the OS data should address how they attempted to mitigate the effects of missing data in analyzing their results and clearly present the limitations of their studies.

Conceptualizing performance of nursing care as a prerequisite for better measurement: a systematic and interpretive review

BACKGROUND

Despite the critical role of nursing care in determining high-performing healthcare delivery, performance science in this area is still at an early stage of development and nursing's contribution most often remains invisible to policy-makers and managers. The objectives of this study were: 1) to develop a theoretically based framework to conceptualize nursing care performance; 2) to analyze how the different components of the framework have been operationalized in the literature; and 3) to develop a pool of indicators sensitive to various aspects of nursing care that can be used as a basis for designing a performance measurement system.

METHODS

We carried out a systematic review of published literature across three databases (MEDLINE, EMBASE and CINAHL), focusing on literature between 1990 and 2008. Screening of 2,103 papers resulted in final selection of 101 papers. A detailed template was used to extract the data. For the analysis, we used the method of interpretive synthesis, focusing first on 31 papers with theoretical or conceptual frameworks; the remaining 70 articles were used to strengthen and consolidate the findings.

RESULTS

Current conceptualizations of nursing care performance mostly reflect a system perspective that builds on system theory, Donabedian's earlier works on healthcare organization, and Parsons' theory of social action. Drawing on these foundational works and the evidence collated, the Nursing Care Performance Framework (NCPF) we developed conceptualizes nursing care performance as resulting from three nursing subsystems that operate together to achieve three key functions: (1) acquiring, deploying and maintaining nursing resources, (2) transforming nursing resources into nursing services, and (3) producing changes in patients' conditions. Based on the literature review, these three functions are operationalized through 14 dimensions that cover 51 variables. The NCPF not only specifies core aspects of nursing performance, it also provides decision-makers with a conceptual tool to serve as a common ground from which to define performance, devise a common and balanced set of performance indicators for a given sector of nursing care, and derive benchmarks for this sector.

CONCLUSIONS

The NCPF provides a comprehensive, integrated and theoretically based model that allows performance evaluation of both the overall nursing system and its subsystems. Such an approach widens the view of nursing performance to embrace a multidimensional perspective that encompasses the diverse aspects of nursing care.

Conceptualizing performance of nursing care as a prerequisite for better measurement: a systematic and interpretive review

BACKGROUND

Despite the critical role of nursing care in determining high-performing healthcare delivery, performance science in this area is still at an early stage of development and nursing's contribution most often remains invisible to policy-makers and managers. The objectives of this study were: 1) to develop a theoretically based framework to conceptualize nursing care performance; 2) to analyze how the different components of the framework have been operationalized in the literature; and 3) to develop a pool of indicators sensitive to various aspects of nursing care that can be used as a basis for designing a performance measurement system.

METHODS

We carried out a systematic review of published literature across three databases (MEDLINE, EMBASE and CINAHL), focusing on literature between 1990 and 2008. Screening of 2,103 papers resulted in final selection of 101 papers. A detailed template was used to extract the data. For the analysis, we used the method of interpretive synthesis, focusing first on 31 papers with theoretical or conceptual frameworks; the remaining 70 articles were used to strengthen and consolidate the findings.

RESULTS

Current conceptualizations of nursing care performance mostly reflect a system perspective that builds on system theory, Donabedian's earlier works on healthcare organization, and Parsons' theory of social action. Drawing on these foundational works and the evidence collated, the Nursing Care Performance Framework (NCPF) we developed conceptualizes nursing care performance as resulting from three nursing subsystems that operate together to achieve three key functions: (1) acquiring, deploying and maintaining nursing resources, (2) transforming nursing resources into nursing services, and (3) producing changes in patients' conditions. Based on the literature review, these three functions are operationalized through 14 dimensions that cover 51 variables. The NCPF not only specifies core aspects of nursing performance, it also provides decision-makers with a conceptual tool to serve as a common ground from which to define performance, devise a common and balanced set of performance indicators for a given sector of nursing care, and derive benchmarks for this sector.

CONCLUSIONS

The NCPF provides a comprehensive, integrated and theoretically based model that allows performance evaluation of both the overall nursing system and its subsystems. Such an approach widens the view of nursing performance to embrace a multidimensional perspective that encompasses the diverse aspects of nursing care.

Can hospital cultural competency reduce disparities in patient experiences with care?

BACKGROUND

Cultural competency has been espoused as an organizational strategy to reduce health disparities in care.

OBJECTIVE

To examine the relationship between hospital cultural competency and inpatient experiences with care.

RESEARCH DESIGN

The first model predicted Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores from hospital random effects, plus fixed effects for hospital cultural competency, individual race/ethnicity/language, and case-mix variables. The second model tested if the association between a hospital's cultural competency and HCAHPS scores differed for minority and non-Hispanic white patients.

SUBJECTS

The National CAHPS Benchmarking Database's (NCBD) HCAHPS Surveys and the Cultural Competency Assessment Tool of Hospitals Surveys for California hospitals were merged, resulting in 66 hospitals and 19,583 HCAHPS respondents in 2006.

MEASURES

Dependent variables include 10 HCAHPS measures: 6 composites (communication with doctors, communication with nurses, staff responsiveness, pain control, communication about medications, and discharge information), 2 individual items (cleanliness and quietness of patient rooms), and 2 global items (overall hospital rating, and whether patient would recommend hospital).

RESULTS

Hospitals with greater cultural competency have better HCAHPS scores for doctor communication, hospital rating, and hospital recommendation. Furthermore, HCAHPS scores for minorities were higher at hospitals with greater cultural competency on 4 other dimensions: nurse communication, staff responsiveness, quiet room, and pain control.

CONCLUSIONS

Greater hospital cultural competency may improve overall patient experiences, but may particularly benefit minorities in their interactions with nurses and hospital staff. Such effort may not only serve longstanding goals of reducing racial/ethnic disparities in inpatient experience, but may also contribute to general quality improvement.

Registered nurse retention strategies in nursing homes: a two-factor perspective

BACKGROUND

As the American population ages and the proportion of individuals over the age of 65 expands, the demand for high-quality nursing home care will increase. However, nursing workforce instability threatens care quality and sustainability in this sector. Despite increasing attention to nursing home staff turnover, far less is known about registered nurse (RN) retention.

PURPOSE

In this study, the relationships between retention strategies, employee benefits, features of the practice environment, and RN retention were explored. Further, the utility of Herzberg's two-factor theory of motivation as a framework for nursing home retention studies was evaluated.

METHODOLOGY

This study was a secondary analysis of the nationally representative 2004 National Nursing Home Survey. The final sample of 1,174 participating nursing homes were either certified by Medicare or Medicaid or licensed by state agencies. We used a weighted multinomial logistic regression using an incremental approach to model the relationships.

FINDINGS

Although most nursing homes offered some combination of retention programs, the majority of strategies did not have a significant association with the level of RN retention reported by facilities. Director of nursing tenure and other extrinsic factors had the strongest association with RN retention in adjusted analyses.

PRACTICE IMPLICATIONS

To improve RN retention, organizations may benefit greatly from stabilizing nursing home leadership, especially the director of nursing position. Second, managers of facilities with poor retention may consider adding career ladders for advancement, awarding attendance, and improving employee benefits. As a behavioral outcome of motivation and satisfaction, retention was not explained as expected using Herzberg's two-factor theory.

The impact of organizational factors on the urinary incontinence care quality in long-term care hospitals: a longitudinal correlational study

BACKGROUND

With the rapid increase in the number of long-term care hospitals in Korea, care quality has become an important issue. Urinary incontinence is an important condition affecting many residents' quality of life. Thus, it is important that urinary incontinence be amenable to improving conditions with appropriate interventions, since a change in urinary incontinence status can reflect care quality in long-term care facilities if patient level factors are adjusted.

OBJECTIVES

We aim to examine the impact of organizational factors on urinary incontinence care quality defined as the improvement of urinary incontinence status or maintenance of continent status post-admission to Korean long-term care hospitals. DESIGN AND DATA: This is a longitudinal correlation study. Data came from two sources: monthly patient assessment reports using the Patient Assessment Instrument and the hospital information system from the Health Insurance Review and Assessment Services. The final analysis includes 5271 elderly adults without indwelling urinary catheter or urostomy who were admitted to 534 Korean long-term care hospitals in April 2008.

METHODS

Multi-level logistic analysis was used to explore the organizational factors that influence urinary incontinence care quality controlling for patient level factors.

RESULTS

With respect to the organizational factors, the findings showed that location and RN/total nursing staff ratio variables were statistically significant, controlling for risk factors at the patient level. The odds of urinary incontinence improvement from admission in urban long-term care hospitals were 1.28 times higher than rural long-term care hospitals. In addition, when a long-term care hospital increased one standard deviation (0.19) in the RN ratio, the odds of urinary incontinence status improvement or maintenance of continence status from admission increased about 1.8 times.

CONCLUSIONS

The most significant finding was that a higher RN to patient ratio and urban location were associated with better resident outcomes of urinary incontinence among organizational factors. For a better understanding of how these significant organizational factors influence positive care outcomes and provide more practical implications, studies should examine concrete care process measures as well as structure and outcome measures based on systematic conceptual models.

Health-related quality of life: expanding a conceptual framework to include older adults who receive long-term services and supports

For older adults receiving long-term services and supports (LTSS), health-related quality of life (HRQoL) has emerged as a critical construct to examine because of its focus on components of well-being, which are affected by progressive changes in health status, health care, and social support. HRQoL is a health-focused quality of life (QOL) concept that encompasses aspects of QOL that affect health such as function, physical, and emotional health. Examining existing theoretical constructs and indicators of HRQoL among LTSS recipients led us to posit a revised conceptual framework for studying HRQoL among LTSS recipients. We adapted the Wilson and Cleary HRQoL model by expanding function to specifically include cognition, adding behavior and LTSS environmental characteristics in order to create a more robust HRQoL conceptual framework for older adults receiving LTSS. This refined conceptual model allows for the measurement of a mix of structural, process, and outcome measures. Continued development of a multidimensional conceptual framework with specific HRQoL measures that account for the unique characteristics of older adults receiving LTSS will contribute significantly to LTSS research, policy, and planning efforts.

Quality of care and quality of dying in nursing homes: two measurement models

BACKGROUND

There is consistent evidence of significant variation in the quality of end-of-life care among nursing homes, with many facilities ill-prepared to provide optimal physical and psychological care that is culturally sensitive and respectful of the needs and preferences of residents and their family members. There is continued evidence that what is impeding efforts to improve care is that most measurement tools are hampered by a lack of distinction between quality of care and quality of dying as well as a lack of complete psychometric evaluation. Further, health services researchers cite the need to include "system-level" factors, variables that reflect leadership, culture, or informal practices, all of which influence end-of-life care and can be used to differentiate one setting from another. The purpose of this article is to report advancement in conceptualizing quality end-of-life care in nursing homes and to offer a refined approach to measurement.

METHODS

Two latent constructs are tested: quality of care (composed of system-level factors) and quality of dying (comprised of resident/family outcomes). Data obtained from 85 Midwestern nursing homes and 1282 interviews with bereaved family members were used to evaluate both constructs.

RESULTS

Confirmatory factor analyses were conducted and evidence of validity and reliability were obtained for both.

CONCLUSION

For health services researchers, expanded models that include system-level factors as well as more comprehensive and psychometrically sound models of resident outcomes stand to inform efforts to improve care in this very important area.

Director of nursing current job tenure and past experience and quality of care in nursing homes

BACKGROUND

Directors of nursing (DONs) are central to quality of care in nursing homes (NHs) because of their role in coordinating and overseeing nursing care. Research is needed to test the association between DON characteristics and quality using large, representative samples of NHs and global measures of quality. One such measure is the quality measure (QM) rating from the Centers for Medicare & Medicaid Services' Five-Star Quality Rating, which aggregates 10 individual QMs into a single rating.

PURPOSE

This study examined whether DON current job tenure or past experience (a) differed across levels of the QM rating, (b) was associated with QM ratings, and (c) was associated with any of the individual 10 QM scores that comprise QM ratings.

METHODOLOGY

Data for a nationally representative sample of 1,174 NHs were obtained from the 2004 National Nursing Home Survey, publicly reported QMs, and an Area Resource File. Wald tests were used to test differences in mean DON current job tenure and past experience across levels of the QM rating. Multinomial logistic and Poisson regression analyses were used to examine the association between DON current job tenure and past experience and QM ratings and QM scores, respectively, controlling for selected market and organizational characteristics.

FINDINGS

Nursing homes with longer DON current job tenure tended to have higher QM ratings. Longer DON current job tenure was associated with higher QM ratings and lower QM scores for several individual QMs, suggesting higher quality. The past experience of the DON did not differ across levels of the QM rating and was not associated with QM ratings or QM scores.

PRACTICE IMPLICATIONS

This study highlights the need for owners and administrators to support DONs as they either the transition into the role of the DON for the first time or learn to effectively fulfill their role in a new NH.

A knowledge based search tool for performance measures in health care systems

Performance measurement is vital for improving the health care systems. However, we are still far from having accepted performance measurement models. Researchers and developers are seeking comparable performance indicators. We developed an intelligent search tool to identify appropriate measures for specific requirements by matching diverse care settings. We reviewed the literature and analyzed 229 performance measurement studies published after 2000. These studies are evaluated with an original theoretical framework and stored in the database. A semantic network is designed for representing domain knowledge and supporting reasoning. We have applied knowledge based decision support techniques to cope with uncertainty problems. As a result we designed a tool which simplifies the performance indicator search process and provides most relevant indicators by employing knowledge based systems.

Changes in nursing home staffing levels, 1997 to 2007

A positive relationship has been demonstrated between the quality of care delivered in nursing homes and the quality of nursing staff providing the care. The general perception, however, is that there is a decline in registered nurses' staff hours in nursing homes. The primary objective of this study is to investigate whether the levels of registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants (NAs) as well as skill mix has changed in nursing homes between the years 1997 and 2007. A descriptive research design was employed on data derived from Online Survey Certification and Reporting System database. After accounting for facility size and ownership, it was found that more nursing homes have increased-rather than decreased-LPN and NA hours per resident day between 1997 and 2007. On the other hand, more nursing homes have decreased-rather than increased-RN hours per resident day and skill mix during the same time period.

Registered nurse staffing mix and quality of care in nursing homes: a longitudinal analysis

PURPOSE

To examine the relationship between registered nurse (RN) staffing mix and quality of nursing home care measured by regulatory violations.

DESIGN AND METHODS

A retrospective panel data study (1999-2003) of 2 groups of California freestanding nursing homes. One group was 201 nursing homes that consistently met the state's minimum standard for total nurse staffing level over the 5-year period. The other was 210 nursing homes that consistently failed to meet the standard over the period. All facility and market variables were drawn from California's cost report data and state licensing and certification data, as well as 3 other databases.

RESULTS

The RN to total nurse staffing ratio was negatively related to serious deficiencies in nursing homes that consistently met the staffing standard, whereas the ratio was negatively associated with total deficiencies in nursing homes that consistently failed to meet the standard over the 5-year period. As the RN to licensed vocational nurse ratios increased, total deficiencies and serious deficiencies decreased in both groups of nursing homes.

IMPLICATIONS

A higher RN mix is positively related to quality of care, but the relationship is affected by overall nurse staffing levels in nursing homes. Further studies are necessary for a better understanding of RNs' unique contributions to the quality of care in nursing homes.

Daily practice teams in nursing homes: evidence from New York state

PURPOSE

Most health care organizations, including nursing homes, report having teams. However, little is known about everyday practice teams among staff providing direct resident care. We assess the prevalence of such teams in nursing homes as reported by direct care staff and administrators, and examine characteristics of facilities that foster these teams.

DESIGN AND METHODS

The analytical model is based on 149 nursing homes. Data sources include surveys of administrators (n = 292) and direct care staff (n = 6,867), and Online Survey Certification and Reporting System. Linear regression with robust standard errors and sampling probability weights is used to examine the relationship between daily practice teams and facility characteristics.

RESULTS

On average, 16% of workers per facility report practicing in formal multidisciplinary teams providing daily resident care. Team prevalence is 3.3% higher when managers view teams as very important for clinical care quality, 2.6% higher when the directors of nursing report formally organized teams, 2.5% higher for each 10% increase in workers' involvement in teams other than the daily practice teams, and 1.95% higher for each 1-hr increase in nursing hours.

IMPLICATIONS

Our study shows that multidisciplinary daily practice teams can be found in most facilities in our large sample, but their penetration within nursing homes is far from pervasive; in 72% of facilities, staff report team prevalence of less than 25%. Given that the majority of managers report teamwork as very important to their facilities' operations, we discuss why only a relatively small proportion of daily care is provided in this fashion.

Assessing nursing home care quality through Bayesian networks

This article demonstrates how Bayesian networks can be employed as a tool to assess the quality of care in nursing homes. For the data sets analyzed, the proposed model performs comparably to existing quantitative assessment models. In addition, a Bayesian network approach offers several unique advantages. The structure and parameters of a Bayesian network provide rich insight into the multidimensional aspects of the quality of care. Bayesian networks can be used as a guide in implementing limited resources by identifying information that would be most relevant to an assessment. Finally, Bayesian networks provide a straightforward framework for integrating nursing home care quality research that is conducted in various locations and for various purposes.

Nursing home care quality: insights from a Bayesian network approach

PURPOSE

The purpose of this research is twofold. The first purpose is to utilize a new methodology (Bayesian networks) for aggregating various quality indicators to measure the overall quality of care in nursing homes. The second is to provide new insight into the relationships that exist among various measures of quality and how such measures affect the overall quality of nursing home care as measured by the Observable Indicators of Nursing Home Care Quality Instrument. In contrast to many methods used for the same purpose, our method yields both qualitative and quantitative insight into nursing home care quality.

DESIGN AND METHODS

We construct several Bayesian networks to study the influences among factors associated with the quality of nursing home care; we compare and measure their accuracy against other predictive models.

RESULTS

We find the best Bayesian network to perform better than other commonly used methods. We also identify key factors, including number of certified nurse assistant hours, prevalence of bedfast residents, and prevalence of daily physical restraints, that significantly affect the quality of nursing home care. Furthermore, the results of our analysis identify their probabilistic relationships.

IMPLICATIONS

The findings of this research indicate that nursing home care quality is most accurately represented through a mix of structural, process, and outcome measures of quality. We also observe that the factors affecting the quality of nursing home care collectively determine the overall quality. Hence, focusing on only key factors without addressing other related factors may not substantially improve the quality of nursing home care.

Where should Momma go? Current nursing home performance measurement strategies and a less ambitious approach

Background

Nursing home performance measurement systems are practically ubiquitous. The vast majority of these systems aspire to rank order all nursing homes based on quantitative measures of quality. However, the ability of such systems to identify homes differing in quality is hampered by the multidimensional nature of nursing homes and their residents. As a result, the authors doubt the ability of many nursing home performance systems to truly help consumers differentiate among homes providing different levels of quality. We also argue that, for consumers, performance measurement models are better at identifying problem facilities than potentially good homes.

Discussion

In response to these concerns we present a proposal for a less ambitious approach to nursing home performance measurement than previously used. We believe consumers can make better informed choice using a simpler system designed to pinpoint poor-quality nursing homes, rather than one designed to rank hundreds of facilities based on differences in quality-of-care indicators that are of questionable importance. The suggested performance model is based on five principles used in the development of the Consumers Union 2006 Nursing Home Quality Monitor.

Summary

We can best serve policy-makers and consumers by eschewing nursing home reporting systems that present information about all the facilities in a city, a state, or the nation on a website or in a report. We argue for greater modesty in our efforts and a focus on identifying only the potentially poorest or best homes. In the end, however, it is important to remember that information from any performance measurement website or report is no substitute for multiple visits to a home at different times of the day to personally assess quality.

Non-normal path analysis in the presence of measurement error and missing data: a Bayesian analysis of nursing homes' structure and outcomes

Path analytic models are useful tools in quantitative nursing research. They allow researchers to hypothesize causal inferential paths and test the significance of these paths both directly and indirectly through a mediating variable. A standard statistical method in the path analysis literature is to treat the variables as having a normal distribution and to estimate paths using several least squares regression equations. The parameters corresponding to the direct paths have point and interval estimates based on normal distribution theory. Indirect paths are a product of the direct path from the independent variable to the mediating variable and the direct path of the mediating variable to the dependent variable. However, in the case of non-normal distributions, the point and interval estimates of the indirect path become much more difficult to estimate. We address the issue of calculating indirect point and interval estimates in the case of non-normally distributed data. Our substantive application is a nursing home research problem in which the variables in the path analysis of interest involve variables with normal, Bernoulli, or Poisson distributions. Additionally, one of the Poisson variables is observed with error. This paper addresses estimating point and interval estimation of indirect paths for variables with non-normal distributions in the presence of missing data and measurement error. We handle these difficulties from a fully Bayesian point of view. We present our substantive path analysis motivated from a nursing home structure, process, and outcomes model. Our results focus on the impact job turnover in the nursing homes has on nursing home outcomes.

Predictors of resident outcome improvement in nursing homes

The effects of contextual characteristics and nursing-related factors on the overall quality improvement of resident outcomes, measured by a weighted index in incidents of pressure ulcers, physical restraints, and catheter use in nursing homes, were investigated by autoregressive latent trajectory modeling of panel data (1997-2003). Findings show that in the initial study period, nursing homes with a smaller bed size, being for-profit, caring for more Medicare residents, having residents with lower acuity levels, being located elsewhere than the South, having a high level of nurse staffing, and certified with lower frequencies of nursing care deficiencies had better quality. The intercept factor, representing the baseline of quality, was well predicted by six of the eight contextual and facility characteristics variables, and the slope trajectory of quality was only weakly predicted by them. The improved quality in resident outcomes was associated with facilities having fewer nursing care deficiency citations than their counterparts.

The quality of care in Norwegian nursing homes

BACKGROUND

Promoting the quality of life is an importing aim of the long-term care for the elderly, and the quality of life is related to quality of care (QoC). This way the QoC in nursing homes, and its correlates, is an interesting subject.

AIM

To describe to what degree Norwegian nursing homes provide services in line with the core areas of the 'regulation of care' and whether patient or ward characteristics are associated with the QoC.

METHODS AND MATERIAL

Cross-sectional study where data were collected in structured interview of the nursing staff in 251 wards regarding 1926 patients.

RESULTS

Most of the patients receive good basic care in Norwegian nursing homes, but taking part in leisure activities and having the opportunity to go out for a walk are more often neglected. Acceptable QoC had a strongly negative association with patient characteristics such as low function in mental capacity, low function in activities of daily living and aggressive behaviour. In most of the measured areas of QoC, ward characteristics, such as type of ward, size of ward and staffing ratio, do have an influence on QoC.

The Measurement of Nursing Home Quality: Multilevel Confirmatory Factor Analysis of Panel Data

This study examined the validity of a measurement model of nursing home quality by using multilevel confirmatory factor analysis. Based on Mullan and Harrington's (2001) facility-level quality measurement model, a two-level analysis (facility and state) of the measurement model were performed. Two research questions were asked: (1) Can the measurement model developed at the facility-level be applied to state-level nursing home quality measurement? (2) Is the measurement model of nursing home quality stable over time? Panel data of 1997 and 2001, from the national OSCAR database, were used to test the assumptions. The results show that the state-level measurement model fits the data better than the facility-level model does. When the indicator "assessment" was removed from the state-level measurement model, a better-fitted measurement model was found. The two-level measurement model is relatively stable over time, demonstrating the construct validity of this measurement model.