Nursing Home Staff Turnover and Perceived Patient Safety Culture: Results from a National Survey

Factors Associated With Registered Nurses' Safety Nursing Activities in Nursing Homes

PURPOSE

A key challenge in quality improvement is ensuring resident safety, especially in nursing homes. However, few studies have comprehensively examined safety nursing activities and explored the possible contributing factors, such as organizational or individual factors, within this context. This study analyzes safety nursing activities in nursing homes and explores the relationship between organizational and individual factors regarding these activities.

METHODS

In total, 38 nursing homes and 151 individual registered nurses were surveyed. Data were analyzed using multilevel regression analysis.

RESULTS

Registered nurse-related factors, teamwork, organizational nursing home-related factors, and the ratio of registered nurses to residents were significant factors associated with safety nursing activities.

CONCLUSIONS

To increase registered nurses' safety nursing activities, it is necessary to assess how well the team functions in nursing homes and develop interventions to improve team efficiency, including increasing the number of registered nurses to ensure sufficient time for safety nursing activities.

Leadership Matters: Investigating the Association Between Nursing Home Administrator Turnover and Quality

BACKGROUND AND OBJECTIVES

Existing research has associated nursing home (NH) staff turnover with poor performance, yet the impact of nursing home administrator (NHA) turnover remains relatively understudied. This study aimed to explore the relationship between NHA turnover and NH quality, and to determine if this relationship was mediated by registered nurse (RN) turnover.

RESEARCH DESIGN AND METHODS

Utilizing data from multiple secondary sources, including the Care Compare: Skilled Nursing Facility Quality Reporting Program (SNF QRP) and LTCFocus.org, this study employed a longitudinal analysis covering the period 2021-2022 (n = 19,645). The dependent variable was quality star ratings from SNF QRP, whereas the independent variable was NHA turnover, reflecting the number of administrators who left each facility annually. We used Baron and Kenny's mediation testing method, incorporating 2-way fixed effects (state and year level) with appropriate organizational and market level control variables.

RESULTS

The results affirmed that NHA turnover negatively affected quality, decreasing the likelihood of a higher star rating by 14% with one departure and 25% with multiple departures (p = .001). Additionally, NHA turnover correlated with an increase in RN turnover by 7% and 11%, respectively, for one and multiple departures (p = .001). RN turnover fully mediated the impact of NHA turnover on quality, nullifying the direct effect of NHA turnover.

DISCUSSION AND IMPLICATIONS

The results of this study highlight the synergistic relationship between administrators and caregivers in NHs. To enhance NHA retention, NHs should improve compensation and benefits. Nonetheless, broader governmental support and interventions might be necessary to sustain these improvements.

Clinical leadership in nursing homes: A qualitative study of healthcare professionals' perspectives on concept and characteristics

AIM(S)

To conceptualise and identify characteristics of clinical leadership in the nursing home setting.

DESIGN

A qualitative study using semi-structured focus group interviews and a thematic analysis.

METHODS

Five semi-structured focus group interviews were conducted with 41 healthcare professionals from nursing and other healthcare disciplines working in nursing homes (such as nurse assistants, licensed practical nurses, registered nurses (RNs), occupational therapists, recreational therapists, psychologists and gerontologists). Qualitative thematic content analysis of the gathered data was done.

RESULTS

Clinical leaders in nursing homes can be defined as passionate healthcare professionals providing person-centred care with strong communication skills. They are clinical experts in their field and motivated to engage in lifelong learning. They are team players with informal leadership skills. They are visionary, committed, resilient and responsive. Awareness of the definition and the main characteristics of clinical leadership is necessary to facilitate the identification, support and development of healthcare professionals. Focussing on the development of competencies, training courses and monitoring and assessment methods is necessary to improve the evidence of clinical leadership in nursing homes.

Psychometric properties of the Indonesian version of the nursing home survey on patient safety culture

INTRODUCTION

The development of resident safety culture in nursing homes (NH) represents a major challenge for governments and NH owners, with a requirement for suitable tools to assess safety culture. Indonesia currently lacks suitable safety cultures scales for NH.

OBJECTIVES

To evaluate the psychometric properties of the translated Indonesian version of the Nursing Home Survey on Patient Safety Culture (NHSOPSC-INA).

METHODS

This study was a cross-sectional survey conducted using NHSOPSC-INA. A total of 258 participants from 20 NH in Indonesia were engaged. Participants included NH managers, caregivers, administrative staff, nurses and support staff with at least junior high school education. The SPSS 23.0 was used for descriptive data analysis and internal consistency (Cronbach's alpha) estimation. The AMOS (version 22) was used to perform confirmatory factor analysis (CFA) on the questionnaire's dimensional structure.

RESULTS

The NHSOPSC CFA test originally had 12 dimensions with 42 items and was modified to eight dimensions with 26 items in the Indonesian version. The deleted dimensions were 'Staffing' (4 items), 'Compliance with procedure' (3 items), 'Training and skills' (3 items), 'non-punitive response to mistakes' (4 items) and 'Organisational learning' (2 items). The subsequent analysis revealed an accepted model with 26 NHSOPSC-INA items (root mean square error of approximation = 0.091, comparative fit index = 0.815, Tucker-Lewis index = 0.793, CMIN = 798.488, df = 291, CMIN/Df = 2.74, GFI = 0.782, AGFI = 0.737, p < 0.0001) and a factor loading value of 0.538-0.981. Expert feedback confirmed the relevance of the instrument items (content validity index [CVI] = 0.942).

CONCLUSION

The modified NHSPOSC-INA model with eight dimensions (26 items) fits the data set in the context of Indonesian NH services.

IMPLICATIONS FOR PRACTICE

The NHSPOSC-INA is a valid and reliable instrument for assessing staff perceptions of NH resident safety culture in Indonesia. The questionnaire can now be used to evaluate interventions for resident safety in Indonesian NH.

Turnover intention and retention of newly licensed nurses in their first job: A longitudinal study

AIM

To examine newly licensed nurses' retention in their first job and factors related to their turnover.

BACKGROUND

Newly licensed nurses have a high turnover rate within three years of entering their first job.

INTRODUCTION

The factors affecting newly licensed nurses' turnover should be identified and prevented.

METHODS

This longitudinal study tracked newly licensed nurses for three years. Data were collected online, and nurses could participate four times in the survey. The Kaplan-Meier method was used to estimate survival curves and to present nurses' retention. Cox proportional hazards regression model was used to analyze factors related to turnover.

RESULTS

The estimated survival probabilities in nurses' first job at one, two, and three years were 0.927, 0.778, and 0.686, respectively. Nurses who reported turnover intention within one year in the first survey had significantly lower survival probabilities than those who did not have turnover intention. Turnover was more likely among male nurses. Turnover intention was associated with a significant increased likelihood of nurses leaving their first job.

DISCUSSION

More than one third of newly licensed nurses left their first job within three years of employment. To reduce nurses' turnover, it is necessary to understand and manage turnover intention in advance. Specific steps should be taken to address male nurses' turnover.

CONCLUSIONS

Turnover intention was the most powerful predictor of turnover. Further research should investigate reasons for turnover intention at the beginning of employment, and strategies to prevent turnover should be developed before nurses enter the workforce.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Newly licensed nurses with turnover intention at the beginning of their career should receive particular attention, and wellness programs should be prepared to promote retention.

An integrative review of research evaluating organisational culture in residential aged care facilities

BACKGROUND

Evidence suggests that the culture of healthcare organisations, including residential aged care facilities (RACFs), is linked to the quality of care offered. The number of people living in RACFs has increased globally, and in turn, attention has been placed on care quality. This review aimed to identify how organisational culture is studied, sought to elucidate the results of previous studies, and aimed to establish what interventions are being used to improve organisational culture in RACFs.

METHODS

We employed an integrative review design to provide a comprehensive understanding of organisational culture. Five academic data bases were searched (Ovid Medline, Scopus, PsycInfo, CINAHL, Embase). Articles were included if they were empirical studies, published in peer reviewed journals in English, conducted in a RACF setting, and were focused on organisational culture/climate.

RESULTS

Ninety-two articles were included. Fifty-nine studies (64.1%) utilised a quantitative approach, while 24 (26.0%) were qualitative, and nine used mixed methods (9.8%). Twenty-two (23.9%) aimed to describe the culture within RACFs, while 65 (70.7%) attempted to understand the relationship between culture and other variables, demonstrating mixed and indeterminate associations. Only five (5.4%) evaluated an intervention.

CONCLUSIONS

This review highlights the heterogenous nature of this research area, whereby differences in how culture is demarcated, conceptualised, and operationalised, has likely contributed to mixed findings. Future research which is underpinned by a sound theoretical basis is needed to increase the availability of empirical evidence on which culture change interventions can be based.

Patient Safety Subcultures among Nursing Home Staff in Italy: A Cross-Sectional Study

Nursing home (NH) residents are vulnerable subjects and highly susceptible to adverse events. Knowledge of patient safety culture (PSC) is essential for an organization to ensure patient safety. However, research on PSC in NHs, and its variability among staff, is still scarce. This study aimed to explore whether and how PSC differed among NH staff (Managers, Nurses, Direct Care Staff, Support Staff, Administrative Staff and Other Providers) in the Autonomous Province of Trento, Italy. This study employed a cross-sectional design and collected data from 1145 NH providers using the Nursing Home Survey on Patient Safety Culture (NHSPSC). Data were analyzed using linear mixed models, with each of the 12 NHSPSC domains as a response variable. The majority of the respondents (61.6%) were Direct Care Staff members. 'Feedback and Communication about Incidents' and 'Overall Perceptions of Resident Safety' were the domains with the highest proportions of positive answers (PPAs). For most staff categories, 'Staffing' was the domain with the lowest PPA. Support Staff showed significantly lower scores in the majority of domains (8/12). Shorter job tenure, fewer weekly working hours, working mostly during the day and working in highly specialized areas were associated with higher scores in several domains. Interventions to improve PSC must consider the differences between professional groups. Further research is needed to explore the relationship between job-related features and perceptions of patient safety among NH workers.

Impact of the COVID-19 pandemic on staff turnover at long-term care facilities: a qualitative study

OBJECTIVE

The objective of this research was to explore the lived experiences of long-term care facilities' staff during the COVID-19 pandemic and examine if and how the pandemic played a role in their decision to leave their jobs.

DESIGN

Qualitative study using thematic analysis of semistructured interviews. Interview transcripts were analysed using coding techniques based in grounded theory.

PARTICIPANTS

A total of 29 staff with various roles across 21 long-term care facilities in 12 states were interviewed.

RESULTS

The pandemic influenced the staff's decision to leave their jobs in five different ways, namely: (1) It significantly increased the workload; (2) Created more physical and emotional hazards for staff; (3) Constrained the facilities and their staff financially; (4) Deteriorated morale and job satisfaction among the staff and (5) Increased concerns with upper management's commitment to both general and COVID-19-specific procedures.

CONCLUSIONS

Staff at long-term care facilities discussed a wide variety of reasons for their decision to quit their jobs during the pandemic. Our findings may inform efforts to reduce the rate of turnover in these facilities.

Patient Safety Culture in Assisted Living: Staff Perceptions and Association with State Regulations

OBJECTIVES

To examine perceptions of patient safety culture (PSC) among assisted living (AL) administrators and direct care workers (DCWs), and their associations with state regulations.

DESIGN

We conducted a survey using the PSC instrument developed by the Agency for Healthcare Research & Quality. Secondary data on ALs and residents were derived from the Medicare Master Beneficiary Summary Files. Other data sources were the Area Health Resource Files, a previously compiled national AL directory, and the US census. Data on state AL regulations were available from a prior study.

SETTING AND PARTICIPANTS

Participants included administrators and DCWs working in assisted living communities serving Medicare beneficiary residents.

METHODS

We employed exploratory factor analysis, examined Pearson correlations, and obtained standardized Cronbach alphas to test the PSC instrument. We estimated linear regression models with the dependent variable being the proportion of positive PSC assessments, for each PSC domain, with SEs clustered at the AL level.

RESULTS

Surveys were completed by 714 administrators and DCWs in 257 ALs. The PSC instrument tested reliable and valid for AL communities. Administrators' and DCWs' perceptions of PSC differed significantly across almost all domains. A 1-unit increase in state regulatory specificity for DCW staffing was associated with a 4.13-percentage point (P < .05) increase in the PSC staffing domain. Associations with regulatory specificity in staff training were also found for other PSC domains.

CONCLUSIONS AND IMPLICATIONS

PSC is an important metric for assessing organizational performance. DCWs have significantly worse perceptions of PSC than do administrators, suggesting it is crucial to understand the source of these differing perceptions. Because state regulations relate to PSC, achieving a comprehensive focus on patient safety in AL may require regulatory action, particularly increasing specificity with regard to staffing and training.

Patient safety measurement tools used in nursing homes: a systematic literature review

Background

An increase in the number of older adults has highlighted the important issue of the safety of residents in nursing homes. This review aimed to review previous studies on patient safety of older adults living in nursing homes, analyze the tools used to measure it, and identify factors affecting patient safety of older adult residents in nursing homes.

Methods

A literature search was conducted using EMBASE, PubMed, CINHAL, and COCHRANE. The main search terms were “nursing home” or “skilled nursing facility” or “long-term care facility” and “patient safety.” In total, 13,586 articles were identified. Two authors independently assessed the quality of each selected study using the Crowe Critical Appraisal Tool.

Results

Twenty-five studies were included in the analysis. There were a total of seven tools used to measure patient safety in nursing homes: the Nursing Home Survey on Patient Safety Culture (10 studies) and Hospital Survey on Patient Safety Culture (nine studies). Furthermore, the Nursing Home Survey on Patient Safety Culture-China, Safety Attitudes Questionnaire, Safety Attitudes Questionnaire in a Skilled Nursing Facility, Safety Attitudes Questionnaire-Ambulatory Version, and Modified Stanford Patient Safety Culture Survey Instrument were used in one study each. The most used tool among them was the Nursing Home Survey on Patient Safety Culture. Most tools used to measure patient safety in nursing homes were related to patient safety culture and employee attitudes.

Conclusion

Organizational factors, such as the staff education system and the composition of appropriate personnel, should be strengthened to establish a patient safety culture in nursing homes, for which policy support is crucial.

Job Resignation in Nursing Homes During the COVID-19 Pandemic: The Role of Quality of Employer Communication

Limited research has examined coronavirus disease 2019 (COVID-19)-related work stressors experienced by nursing home (NH) employees and how these stressors may impact employees' decision to resign when taking organizational factors into account. Thus, the purpose of this study was to investigate whether quality of employer communication related to COVID-19 and staff preparedness to care for residents with COVID-19 can mediate the effects of COVID-19-related stressors on NH employees' (N = 1,730) decision to resign. Results from path analyses indicate that higher quality of communication and more optimal preparedness mediated the relationship between COVID-19-related stressors and likelihood of resignation. Specifically, higher levels of COVID-19-related stressors were indirectly associated with reduced likelihood of resigning through the paths of more optimal communication and preparedness. Findings underscore the importance of effective employer communication during emergencies in NHs.

Nursing Home Residents With Dementia: Association Between Place of Death and Patient Safety Culture

BACKGROUND AND OBJECTIVES

Nursing homes (NHs) care for 70% of Americans dying with dementia. Many consider deaths in NHs rather than hospitals as preferable for most of these residents. NH characteristics such as staff teamwork, communication, and other components of patient safety culture (PSC), together with state minimum NH nurse staffing requirements, may influence location of death. We examined associations between these variables and place of death (NH/hospital) among residents with dementia.

RESEARCH DESIGN AND METHODS

Cross-sectional study of 11,957 long-stay NH residents with dementia, age 65+, who died in NHs or hospitals shortly following discharge from one of 800 U.S. NHs in 2017. Multivariable logistic regression systematically estimated effects of PSC on odds of in-hospital death among residents with dementia, controlling for resident, NH, county, and state characteristics. Logistic regressions also determined moderating effects of state minimum NH nurse staffing requirements on relationships between key PSC domains and location of death.

RESULTS

Residents with dementia in NHs with higher PSC scores in communication openness had lower odds of in-hospital death. This effect was stronger in NHs located in states with higher minimum NH nurse staffing requirements.

DISCUSSION AND IMPLICATIONS

Promoting communication openness in NHs across nursing disciplines may help avoid unnecessary hospitalization at the end of life, and merits particular attention as NHs address nursing staff mix while adhering to state staffing requirements. Future research to better understand unintended consequences of staffing requirements is needed to improve end-of-life care in NHs.

COVID-19 Preparedness and Perceived Safety in Nursing Homes in Southern Portugal: A Cross-Sectional Survey-Based Study in the Initial Phases of the Pandemic

(1) Background: Nursing homes’ preparedness in managing a public health emergency has been poor, with effects on safety culture. The objective of this study was to assess nursing homes’ COVID-19 preparedness in southern Portugal, including staff’s work experiences during the pandemic. (2) Methods: We used a COVID-19 preparedness checklist to be completed by management teams, followed by follow-up calls to nursing homes. Thereafter, a survey of staff was applied. Data analysis included descriptive statistics, exploratory factor analysis, and thematic analysis of open-end questions. (3) Results: In total, 71% (138/195) of eligible nursing homes returned the preparedness checklist. We conducted 83 follow-up calls and received 720 replies to the staff survey. On average, 25% of nursing homes did not have an adequate decision-making structure to respond to the pandemic. Outbreak capacity and training were areas for improvement among nursing homes’ contingency plans. We identified teamwork as an area of strength for safety culture, whereas compliance with procedures and nonpunitive response to mistakes need improvement. (4) Conclusions: To strengthen how nursing homes cope with upcoming phases of the COVID-19 pandemic or future public health emergencies, nursing homes’ preparedness and safety culture should be fostered and closely monitored.

It Is Time to Resolve the Direct Care Workforce Crisis in Long-Term Care

Nearly 4.6 million direct care workers-including personal care aides, home health aides, and nursing assistants-provide daily support to older adults and people with disabilities across a range of settings in the United States, predominantly in long-term care (LTC). Even as the population grows older and drives up demand for LTC, the sector continues its decades-long struggle to fill direct care positions and stabilize this essential workforce. Recent events and emerging trends have converged, however, to produce new opportunities to address this longstanding workforce crisis, including the unprecedented attention generated by the coronavirus disease 2019 (COVID-19) pandemic and the systemic shifts to managed care and value-based payment in LTC. This Forum article outlines the pressing direct care workforce challenges in LTC before describing these potential levers of change, emphasizing the importance of not just expanding the workforce but also maximizing direct care workers' contributions to the delivery of high-quality services for a growing and evolving population of LTC consumers.

Community Discharge Among Post-Acute Nursing Home Residents: An Association With Patient Safety Culture?

OBJECTIVES

We examined whether better patient safety culture (PSC) in skilled nursing facilities was associated with higher likelihood of successful community discharge for post-acute care residents.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Medicare beneficiaries who were newly admitted for post-acute care (N = 53,929) to skilled nursing facilities participating in PSC survey (N = 818).

METHODS

Facility-level PSC scores were obtained from a national, random survey conducted in 2017. Survey data was linked to Minimum Dataset 3.0, Medicare Provider Analysis and Review, Master Beneficiary Summary File, Nursing Home Compare File, Payroll-Based Journal, and Areal Health Resources File. Successful discharge to community was the outcome of interest. Facility-level PSC scores were the key covariate. We controlled for individual-level, facility-level, and area-level characteristics. Separate logistic regression models for each of the 12 PSC domains and for the overall score were fit.

RESULTS

Post-acute care residents who were successfully discharged to community were more likely to be female (63.7%), white (87.1%), Medicare-only (88.1%), cognitively intact (87.8%), and admitted following a surgery (40.9%) The multivariable analyses showed that teamwork (odds ratio 1.09, P = .02) and supervisor expectations and actions promoting resident safety (odds ratio 1.11, P = .01) were significantly associated with the increased likelihood of successful community discharge.

CONCLUSIONS AND IMPLICATIONS

This is the first study to analyze the relationship between patient safety culture and successful discharge among post-acute care residents. Our results suggest that nursing home leaders may want to focus their quality and safety improvement efforts on specific PSC domains (eg, teamwork) as means for improving community discharge for post-acute care residents.

Facility-Level Factors Associated With CNA Turnover and Retention: Lessons for the Long-Term Services Industry

BACKGROUND AND OBJECTIVES

Certified nursing assistant (CNA) turnover and retention are critical aspects of facilities' ability to provide cost-effective, high-quality person-centered care. Previous studies and industry practice often treat turnover and retention as similar concepts, assuming that low turnover and high retention are synonymous. The study addressed the question of whether turnover and retention rates differ and if so, what those differences mean for nursing home practice, policy, and research.

RESEARCH DESIGN AND METHODS

This study examines facility-level factors associated with CNA retention and turnover rates using 2015 data from the Ohio Biennial Survey of Long-Term Care Facilities, Ohio Medicaid Cost Reports, Certification and Survey Provider Enhanced Report, and the Area Health Resource File. Using bivariate tests and regression analysis, we compare rates and the factors associated with retention and turnover.

RESULTS

The mean facility annual retention rate was 64% and the mean annual turnover rate was 55%. As expected, there was a statistically significant and negative correlation between the rates (r = -0.26). However, some facilities had both high retention and high turnover and some had low rates for both measures. Not all the variables that are associated with turnover are also associated with retention.

DISCUSSION AND IMPLICATIONS

CNA retention is not simply the absence of CNA turnover. Given the differences, nursing homes may need to use strategies and policies designed to target a particular stability measure.