Innovation to enhance health in care homes and evaluation of tools for measuring outcomes of care: rapid evidence synthesis

Background

Flexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme.

Aim

To conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation.

Objectives

(1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes?

Data sources

Searches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search.

Design

Mapping review and rapid, systematic evidence syntheses.

Setting

Care homes with and without nursing in high-income countries.

Review methods

Published literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses.

Results

Seven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising.

Limitations

This review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded.

Conclusions

This review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation.

Future work

Future work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context.

Study registration

This study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Through the Eyes of Nurse Managers in Long-Term Care: Identifying Perceived Competencies and Skills

Nurse managers (NMs) in long-term care supervise health care services for individuals with high acuity levels and numerous comorbidities. There is minimal research identifying NMs' skills and competencies as unit leaders within the long-term care environment. The current mixed-methods study identified NMs' leadership skills and competencies. Nineteen NMs with ≥5 years' long-term care management experience completed the Nurse Manager Inventory Tool and were individually interviewed. They rated their clinical skills at the competent level and their financial/strategic management skills at the novice level. All other skill categories, including leadership reflective practice, diversity, human resource leadership/management, relationship management, performance improvement, and problem solving, were rated at a competent level. Emergent interview qualitative themes included their visibility on the unit, trial and error learning, a sense of "aloneness" due to the absence of other RNs, NM position being a tough job, need for peer support, role modeling, and importance of supporting the resident through their "final journey." [Journal of Gerontological Nursing, 44(5), 32-38.].

Factors Influencing New RNs’ Supervisory Performance in Long-Term Care Facilities

Dans les établissements de soins de longue durée (ÉSLD), les infirmières autorisées (IAs) exercent à la fois des fonctions cliniques et de supervision en tant que membres d’une équipe visant à dispenser des soins de grande qualité aux résidents. Les résidents sont affectés par plusieurs comorbidités et leurs besoins en matière de soins sont complexes. Malheureusement, les infirmières nouvellement agréées ne reçoivent que peu de formation en gérontologie et leur expérience de supervision est minimale, ce qui entraîne de faibles taux de rétention et affecte les résultats chez les patients. Cette étude qualitative a exploré les facteurs influençant l’expérience de supervision des nouvelles IA en ÉSLD à porter d’un échantillon de 24 participants en Ontario (Canada). Les données ont été recueillies par la voie d’entrevues individuelles, et une analyse de contenu directe fut réalisée. Trois niveaux d’influence ont été identifiés : influences personnelles, influences organisationnelles et influences externes. Chacun des niveaux présentait des sous-éléments qui décrivaient plus précisément les facteurs ayant de l’impact sur la performance de la nouvelle IA en supervision. La rétention des nouvelles IA en ÉSLD nécessiterait la mise en place d’une formation additionnelle en gérontologie et d’un processus de mentorat par ces organisations, afin d’assurer le développement de leurs rôles de supervision.

Kansas nurse leader residency programme: advancing leader knowledge and skills

AIMS

To evaluate the effectiveness of the Kansas Nurse Leader Residency (KNLR) programme in improving nurses' leadership knowledge and skills and its acceptability, feasibility and fidelity.

BACKGROUND

The Future of Nursing Report (Institute of Medicine, 2011) calls for nurses to lead change and advance health. The 6-month KNLR programme was developed by the Kansas Action Coalition to support nurses' leadership development.

METHODS

Nurses (n = 36) from four nursing specialties (acute care, long-term care, public health and school health) participated in the programme. The adapted Leader Knowledge and Skill Inventory was used to assess leadership knowledge and skills. Programme acceptability, feasibility and implementation fidelity also were evaluated.

RESULTS

The programme completion rate was 67.7% (n = 24). Programme completers had significantly improved self-assessed and mentor-assessed leadership knowledge and skills (p < .05). These post-programme gains were maintained 3 months after programme completion.

CONCLUSIONS

The KNLR programme effectively improved leadership knowledge and skills and was positively evaluated by participants. The implementation of the KNLR programme using a hybrid format of in-person sessions and online modules was feasible across four specialty areas in both rural and urban regions.

IMPLICATIONS FOR NURSING MANAGEMENT

The next steps include the development of an advanced programme. Residency programmes for new nurse leaders are critical for successful transition into management positions.

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Background

Dementia with challenging behaviour (CB) causes significant distress for caregivers and the person with dementia. It is associated with breakdown of care at home and disruption in care homes. Challenge Demcare aimed to assist care home staff and mental health practitioners who support families at home to respond effectively to CB.

Objectives

To study the management of CB in care homes (ResCare) and in family care (FamCare). Following a conceptual overview, two systematic reviews and scrutiny of clinical guidelines, we (1) developed and tested a computerised intervention; (2) conducted a cluster randomised trial (CRT) of the intervention for dementia with CB in care homes; (3) conducted a process evaluation of implementation of the intervention; and (4) conducted a longitudinal observational cohort study of the management of people with dementia with CB living at home, and their carers.

Review methods

Cochrane review of randomised controlled trials; systematic meta-ethnographic review of quantitative and qualitative studies.

Design

ResCare – survey, CRT, process evaluation and stakeholder consultations. FamCare – survey, longitudinal cohort study, participatory development design process and stakeholder consultations. Comparative examination of baseline levels of CB in the ResCare trial and the FamCare study participants.

Settings

ResCare – 63 care homes in Yorkshire. FamCare – 33 community mental health teams for older people (CMHTsOP) in seven NHS organisations across England.

Participants

ResCare – 2386 residents and 861 staff screened for eligibility; 555 residents with dementia and CB; 277 ‘other’ residents; 632 care staff; and 92 staff champions. FamCare – every new referral (n = 5360) reviewed for eligibility; 157 patients with dementia and CB, with their carer; and 26 mental health practitioners. Stakeholder consultations – initial workshops with 83 practitioners and managers from participating organisations; and 70 additional stakeholders using eight group discussions and nine individual interviews.

Intervention

An online application for case-specific action plans to reduce CB in dementia, consisting of e-learning and bespoke decision support care home and family care e-tools.

Main outcome measures

ResCare – survey with the Challenging Behaviour Scale; measurement of CB with the Neuropsychiatric Inventory (NPI) and medications taken from prescriptions; implementation with thematic views from participants and stakeholders. FamCare – case identification from all referrals to CMHTsOP; measurement of CB with the Revised Memory and Behaviour Problems Checklist and NPI; medications taken from prescriptions; and thematic views from stakeholders. Costs of care calculated for both settings. Comparison of the ResCare trial and FamCare study participants used the NPI, Clinical Dementia Rating and prescribed medications.

Results

ResCare – training with group discussion and decision support for individualised interventions did not change practice enough to have an impact on CB in dementia. Worksite e-learning opportunities were not readily taken up by care home staff. Smaller homes with a less hierarchical management appear more ready than others to engage in innovation. FamCare – home-dwelling people with dementia and CB are referred to specialist NHS services, but treatment over 6 months, averaging nine contacts per family, had no overall impact on CB. Over 60% of people with CB had mild dementia. Families bear the majority of the care costs of dementia with CB. A care gap in the delivery of post-diagnostic help for families supporting relatives with dementia and significant CB at home has emerged. Higher levels of CB were recorded in family settings; and prescribing practices were suboptimal in both care home and family settings.

Limitations

Functionality of the software was unreliable, resulting in delays. This compromised the feasibility studies and undermined delivery of the intervention in care homes. A planned FamCare CRT could not proceed because of insufficient referrals.

Conclusions

A Cochrane review of individualised functional analysis-based interventions suggests that these show promise, although delivery requires a trained dementia care workforce. Like many staff training interventions, our interactive e-learning course was well received by staff when delivered in groups with facilitated discussion. Our e-learning and decision support e-tool intervention in care homes, in its current form, without ongoing review of implementation of recommended action plans, is not effective at reducing CB when compared with usual care. This may also be true for staff training in general. A shift in priorities from early diagnosis to early recognition of dementia with clinically significant CB could bridge the emerging gap and inequities of care to families. Formalised service improvements in the NHS, to co-ordinate such interventions, may stimulate better opportunities for practice models and pathways. Separate services for care homes and family care may enhance the efficiency of delivery and the quality of research on implementation into routine care.

Future work

There is scope for extending functional analysis-based interventions with communication and interaction training for carers. Our clinical workbooks, video material of real-life episodes of CB and process evaluation tool resources require further testing. There is an urgent need for evaluation of interventions for home-dwelling people with dementia with clinically significant CB, delivered by trained dementia practitioners. Realist evaluation designs may illuminate how the intervention might work, and for whom, within varying service contexts.

Trial registration

Current Controlled Trials ISRCTN02553381 (the ResCare trial) and ISRCTN58876649 (the FamCare study).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 15. See the NIHR Journals Library website for further project information.

Long term care nursing competence and related factors among Taiwanese nurses: A national survey for those who completed the LTC training course

The aim of this study was to explore Taiwanese nurses' LTC competence and to examine its relationship with their LTC-related knowledge, care intention, and practical experience. The total sampling was selected from nurses who participated in a 2013 LTC course offered by the Ministry of Health and Welfare. Participants in this study (n = 122) voluntarily provided email addresses and responded to an online survey. A self-developed scale with acceptable reliability and validity was used for data collection. Findings from this study showed median high levels of LTC nursing competence, which was found to be positively correlated with LTC knowledge, care intention, practical experience, continuing education, and marital status. The study revealed that through on-the-job training, nurses' LTC knowledge, care intention, practical experience and nursing competence can be improved, which will benefit the quality of care for LTC clients.

Coping with increased managerial tasks: tensions and dilemmas in nursing leadership

The present study explores how increased managerial tasks affect nursing leadership in Norwegian nursing homes. Responding to New Public Management reforms, increased managerial tasks have been implemented by Norwegian central government into public nursing homes. Even though nursing leadership plays a key role in implementing managerial tasks, it is still unclear how nurses describe the influence of increased managerial tasks in nursing leadership. This was a qualitative study, including 100 hours of observations and 18 semi-structured interviews of nurses holding various positions in three public nursing homes. Thematic analysis was used in analysing data. Three changes were identified in the exercise of nursing leadership: (1) leading daily care from a distance; (2) lack of support in problem-solving; and (3) difficulties in adopting new managerial language. The study demonstrates that managers take on a more administrative role that, in turn, weakens their ability to supervise and motivate nurses in daily care. Lack of a reciprocal relationship between managers and nurses in goal achievement has significantly weakened nursing leadership in nursing homes. The study contributes knowledge on how nursing leadership weakens as a response to changes in nurses’ roles with increased managerial tasks.

Factors associated with high job satisfaction among care workers in Swiss nursing homes - a cross sectional survey study

Background

While the relationship between nurses’ job satisfaction and their work in hospital environments is well known, it remains unclear, which factors are most influential in the nursing home setting. The purpose of this study was to describe job satisfaction among care workers in Swiss nursing homes and to examine its associations with work environment factors, work stressors, and health issues.

Methods

This cross-sectional study used data from a representative national sample of 162 Swiss nursing homes including 4,145 care workers from all educational levels (registered nurses, licensed practical nurses, nursing assistants and aides). Care worker-reported job satisfaction was measured with a single item. Explanatory variables were assessed with established scales, as e.g. the Practice Environment Scale – Nursing Work Index. Generalized Estimating Equation (GEE) models were used to examine factors related to job satisfaction.

Results

Overall, 36.2 % of respondents reported high satisfaction with their workplace, while another 50.4 % were rather satisfied. Factors significantly associated with high job satisfaction were supportive leadership (OR = 3.76), better teamwork and resident safety climate (OR = 2.60), a resonant nursing home administrator (OR = 2.30), adequate staffing resources (OR = 1.40), fewer workplace conflicts (OR = .61), less sense of depletion after work (OR = .88), and fewer physical health problems (OR = .91).

Conclusions

The quality of nursing home leadership–at both the unit supervisor and the executive administrator level–was strongly associated with care workers’ job satisfaction. Therefore, recruitment strategies addressing specific profiles for nursing home leaders are needed, followed by ongoing leadership training. Future studies should examine the effects of interventions designed to improve nursing home leadership and work environments on outcomes both for care staff and for residents.

Leadership and the psychosocial work environment in old age care

Aims and objectives

To study leadership factors and their associations with psychosocial work environmental among nursing assistants who are engaged in old age care and to analyse (i) differences in the assessment of leadership factors and the assessment of psychosocial work environmental in nursing homes and home help services and (ii) the association between the psychosocial work environment and factors that are related to leadership in nursing homes and home help services.

Background

Leadership factors are an important element of the psychosocial work environment in old age care. The physical distance between leaders and nursing assistants is larger in home help services than in nursing homes. Therefore, it is important to study leadership separately in nursing homes and home help services.

Design

Assessments from 844 nursing assistants in nursing homes and 288 in home help services (45 nursing homes and 21 home help service units) were analysed.

Methods

The data were analysed using linear regression. Age, gender, number of staff at the unit, number of years at the current working unit and educational level were controlled in Model 1. Summarised indexes that were based on all independent variables except the main independent variable were additionally controlled in Model 2.

Results

Psychosocial work environment was related to leadership factors, but stronger associations occurred more frequently in nursing homes than in home help services. Empowering leadership, support from superiors, the primacy of human resources and control over decisions were associated with higher assessments on all the variables that were related to the psychosocial work environment in both the nursing homes and home help services.

Conclusions

Organisational differences in conducting leadership in old age care must be considered. Some leadership characteristics are better prerequisites for creating and maintaining a positive psychosocial work environment for nursing assistants in nursing homes and home help services.

Implications for practice

Due to the differences in organisational settings, it is important to consider the differences in prerequisites in conducting leadership. To influence nursing assistants' performance and to increase quality in old age care in the long term, appropriate leadership is necessary.

Securing and Managing Nursing Home Resources: Director of Nursing Tactics

PURPOSE OF THE STUDY

Shrinking resources and increasing demands pose managerial challenges to nursing homes. Little is known about how directors of nursing (DON) navigate resource conditions and potential budget-related challenges. This paper describes the demands-resources tensions that DONs face on a day-to-day basis and the tactics they use to secure and manage resources for the nursing department.

DESIGN AND METHODS

We conducted a secondary analysis of data from a parent study that used a qualitative approach to understand the DON position. A convenience sample of 29 current and previous DONs and administrators from more than 15 states participated in semistructured interviews for the parent study. Data analysis included open coding and thematic analysis.

RESULTS

DONs address nursing service demands-resources tensions in various ways, including tactics to generate new sources of revenue, increase budget allocations, and enhance cost efficiencies.

IMPLICATIONS

The findings provide a rare glimpse into the operational tensions that can arise between resource allocations and demands for nursing services and the tactics some DONs employ to address these tensions. This study highlights the DON's critical role, at the daily, tactical level of adjusting and problem-solving within existing resource conditions. How DONs develop these skills and the extent to which these skills may improve nursing home quality and value are important questions for further practice-, education-, and policy-level investigation.

The role of leadership in the implementation of person-centred care using Dementia Care Mapping: a study in three nursing homes

AIM

The aim of this study was to investigate the role of leadership in the implementation of person-centred care (PCC) in nursing homes using Dementia Care Mapping (DCM).

BACKGROUND

Leadership is important for the implementation of nursing practice. However, the empirical knowledge of positive leadership in processes enhancing person-centred culture of care in nursing homes is limited.

METHOD

The study has a qualitative descriptive design. The DCM method was used in three nursing homes. Eighteen staff members and seven leaders participated in focus-group interviews centring on the role of leadership in facilitating the development process.

RESULTS

The different roles of leadership in the three nursing homes, characterized as 'highly professional', 'market orientated' or 'traditional', seemed to influence to what extent the DCM process led to successful implementation of PCC.

CONCLUSION AND IMPLICATIONS FOR NURSING MANAGEMENT

This study provided useful information about the influence of leadership in the implementation of person-centred care in nursing homes. Leaders should be active role models, expound a clear vision and include and empower all staff in the professional development process.

Leadership, staffing and quality of care in nursing homes

Background

Leadership and staffing are recognised as important factors for quality of care. This study examines the effects of ward leaders' task- and relationship-oriented leadership styles, staffing levels, ratio of registered nurses and ratio of unlicensed staff on three independent measures of quality of care.

Methods

A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data. Five sources of data were utilised: self-report questionnaires to 444 employees, interviews with and questionnaires to 13 nursing home directors and 40 ward managers, telephone interviews with 378 relatives and 900 hours of field observations. Separate multi-level analyses were conducted for quality of care assessed by relatives, staff and field observations respectively.

Results

Task-oriented leadership style had a significant positive relationship with two of the three quality of care indexes. In contrast, relationship-oriented leadership style was not significantly related to any of the indexes. The lack of significant effect for relationship-oriented leadership style was due to a strong correlation between the two leadership styles (r = 0.78). Staffing levels and ratio of registered nurses were not significantly related to any of the quality of care indexes. The ratio of unlicensed staff, however, showed a significant negative relationship to quality as assessed by relatives and field observations, but not to quality as assessed by staff.

Conclusions

Leaders in nursing homes should focus on active leadership and particularly task-oriented behaviour like structure, coordination, clarifying of staff roles and monitoring of operations to increase quality of care. Furthermore, nursing homes should minimize use of unlicensed staff and address factors related to high ratios of unlicensed staff, like low staff stability. The study indicates, however, that the relationship between staffing levels, ratio of registered nurses and quality of care is complex. Increasing staffing levels or the ratio of registered nurses alone is not likely sufficient for increasing quality of care.

Staff outcomes from the caring for aged dementia care resident study (CADRES): a cluster randomised trial

BACKGROUND

Dementia care mapping and person centred care are well-accepted as processes for improving care and well-being for persons with dementia living in the residential setting. However, the impact of dementia care mapping and person centred care on staff has not been well researched.

OBJECTIVES

The impact of person centred care and dementia care mapping compared to each other and to usual dementia care on staff outcomes was examined in terms of staff burnout, general well-being, attitudes and reactions towards resident behavioural disturbances, perceived managerial support, and quality of care interactions.

DESIGN

A cluster-randomised, controlled trial.

SETTINGS

The study was conducted between 2005 and 2007 in 15 residential aged care sites in the Sydney metropolitan area, Australia, with comparable management structures, staffing mix and ratios, and standards of care.

PARTICIPANTS

194 consenting managers, nurses, therapists and nurse assistants working in the participating sites.

METHODS

Intervention care sites received training and support in either person centred care (n=5) or dementia care mapping (n=5); control sites continued with usual dementia care (n=5). Staff outcomes of those three groups were assessed before, directly after the four month intervention (post) and after a further four months (follow-up). The primary outcome measures were the Maslach Burnout Inventory-Human Services Survey and the 12-item General Health Questionnaire. Analysis involved repeated measures analyses of variance for each of the outcome measures and adjustment for potential confounders to limit bias.

RESULTS

The Maslach Burnout Inventory-Human Services Survey results showed that change over time in emotional exhaustion scores differed between the three groups. Post-hoc analyses for each group separately revealed that the only significant time effect was in the dementia care mapping group (p=0.006), with emotional exhaustion scores declining over time. At baseline, more perceived support from management was associated with less emotional exhaustion (r(s)=0.26, p=0.004, n=122) and less depersonalisation (r(s)=0.21, p=0.023, n=122), but not for any of the other outcome measures.

CONCLUSIONS

This study has shown that person centred approaches of care, in particular with dementia care mapping, may contribute to reducing staff job related burnout. The findings also highlight a potentially important role of managerial support and a whole of system approach.

Implementation and Evaluation of LVN LEAD. A leadership and supervisory training program for nursing home charge nurses

Licensed practical/vocational nurses (LVNs) play an important role in U.S. nursing homes, with primary responsibility for supervising unlicensed nursing home staff. Research has shown that the relationship between charge nurses and certified nursing assistants (CNAs) has a significant impact on CNA job satisfaction and turnover as well as quality of care, yet nurses rarely receive supervisory training. The purpose of this project was to develop, pilot, and evaluate a leadership/supervisory training program for LVNs. Upon completion of the training program, many LVNs expressed and demonstrated a new understanding of their supervisory leadership and supervisory responsibilities. Directors of staff development are a potential vehicle for supporting LVNs' development as supervisors.

Quality work in long-term care: the role of first-line leaders

OBJECTIVE

To explore the first-line leaders' role in quality work in long-term care in Norway, in order to determine how that work is related to such success characteristics as leadership, staff, patients, performance, information and information technology.

DESIGN

Cross-sectional telephone survey. The text was analysed using content analysis.

SETTING

Thirty-two Norwegian municipalities stratified according to region and population size.

PARTICIPANTS

Sixty-four first-line leaders in nursing homes and home-based care. Main outcome measure The clinical microsystem approach is used as a framework by defining and designing measureable variables.

RESULTS

Thirty-six leaders described how they initiated and motivated employees to be active in quality work; the remaining leaders indicated that they played a passive role. The first-line leaders played a key role in implementing national quality policies and regulations. The quantity of other success characteristics was low.

CONCLUSIONS

The municipalities delegated the responsibility of implanting national policies to the first-line leaders. Missing were key quality success criteria such as macro- and meso-perspectives for the municipality as a whole and co-operation with other leaders in the organization and fostering of relevant learning. Quality work was fragmented rather than comprehensive and systematic.

Everyday excellence. A framework for professional nursing practice in long-term care

RNs make measurable contributions to the health and wellness of individuals living in nursing homes. However, most nursing homes do not employ adequate numbers of professional nurses with specialized training in the nursing care of older adults to positively affect resident outcomes. As a result, many people never receive excellent geriatric nursing while living in a long-term care facility. Nurses have introduced various professional practice models into health care institutions as tools for leading nursing practice, improving client outcomes, and achieving organizational goals. Problematically, few professional practice models have been implemented in nursing homes. This article introduces an evidence-based framework for professional nursing practice in long-term care. The Everyday Excellence framework is based on eight guiding principles: Valuing, Envisioning, Peopling, Securing, Learning, Empowering, Leading, and Advancing Excellence. Future research will evaluate the usefulness of this framework for professional nursing practice.

Everyday excellence. A framework for professional nursing practice in long-term care

RNs make measurable contributions to the health and wellness of individuals living in nursing homes. However, most nursing homes do not employ adequate numbers of professional nurses with specialized training in the nursing care of older adults to positively affect resident outcomes. As a result, many people never receive excellent geriatric nursing while living in a long-term care facility. Nurses have introduced various professional practice models into health care institutions as tools for leading nursing practice, improving client outcomes, and achieving organizational goals. Problematically, few professional practice models have been implemented in nursing homes. This article introduces an evidence-based framework for professional nursing practice in long-term care. The Everyday Excellence framework is based on eight guiding principles: Valuing, Envisioning, Peopling, Securing, Learning, Empowering, Leading, and Advancing Excellence. Future research will evaluate the usefulness of this framework for professional nursing practice.