Collaboration Between Licensed Nurses and Certified Nurse Aides in the Nursing Home: A Mixed Methods Study

Association of Racial and Ethnic Composition with Staff Levels in Nursing Homes: 2013-2019

OBJECTIVES

The nursing home (NH) population has become increasingly diverse, yet many facilities remain de facto racially segregated. This study examines whether a high proportion of Black, Indigenous, and People of Color (BIPOC) residents is associated with nursing staff levels.

DESIGN

We constructed a longitudinal cohort of NHs (2013-2019) by linking Certification and Survey Provider Enhanced Reports, LTCFocUS.org, Medicare Cost Reports, and Payroll-Based Journal data. Separate multivariable random effects linear regressions were conducted.

SETTING AND PARTICIPANTS

14,075 Medicare- and Medicaid-certified NHs in the United States.

METHODS

The proportion of BIPOC residents was categorized as the 10% of nursing homes serving the highest minority residents in each state each year (High-BIPOC) and the remaining 90% (Low-BIPOC). Total nursing staff levels in hours per resident-day (HPRD) included both hours paid (2013-2019) and hours worked (2017-2019). The total staff included registered nurses, licensed practical nurses, and certified nurse aides.

RESULTS

The unadjusted difference in total staff levels between High-BIPOC and Low-BIPOC NHs increased from -0.23 HPRD (4.19 vs 4.42) in 2013 to -0.35 HPRD (3.94 vs 4.29) in 2019 for hours paid. The difference in hours worked increased from -0.19 (3.55 vs 3.74) in 2017 to -0.23 (3.50 vs 3.73) in 2019. The difference became smaller but remained significant after controlling for covariates (-0.037 HPRD for hours paid, and -0.038 for hours worked). Analyses of individual staff types found lower levels of registered nurses and certified nurse aides (but not licensed practical nurses) among High-BIPOC nursing homes. Findings were robust to treating racial and ethnic composition as a continuous variable or excluding payer mix from the models.

CONCLUSIONS AND IMPLICATIONS

NHs with high concentrations of minority residents reported lower nursing staff levels. Improving staffing in NHs serving primarily marginalized racial and ethnic groups remains a policy priority.

Adding a Mobility Champion to an Existing Progressive Mobility Protocol: An Evidence-Based Initiative

PURPOSE

This evidence-based initiative assessed the effect of adding a mobility champion to an existing progressive mobility protocol on functional decline in hospitalized older adults as evidenced by recommended discharge to home versus an inpatient rehabilitation facility.

METHOD

Older adults admitted from home to a 47-bed medical-surgical telemetry unit who were assessed as ambulatory, either independently or with assistance (Level 5), and with a progressive mobility order in the electronic health record were included in the initiative. Patient care associates who volunteered to be mobility champions were trained how to safely ambulate patients.

RESULTS

Patients who worked with a mobility champion were less likely to be referred to inpatient rehabilitation post discharge for further care due to functional decline.

CONCLUSION

Mobility has a critical role in the maintenance of hospitalized older adults' functional abilities and is a determinate of their post discharge disposition. [Journal of Gerontological Nursing, 50(11), 37-43.].

Increasing interprofessional collaboration in community-based palliative care: a pilot study of the CAPACITI education program for primary care providers

Interprofessional collaboration in palliative care is essential to ensuring high-quality care for seriously ill patients. Education interventions to increase competency in palliative care should incorporate team-building skills to encourage an interprofessional approach. We developed and piloted a virtual educational program named CAPACITI for interprofessional teams to promote a community palliative approach to care. Primary care teams from across Ontario, Canada, participated in CAPACITI which consisted of 10 facilitated sessions that emphasized how to operationalize a palliative care approach as a team. Pre- and post-study questionnaires were completed by each team, including the AITCS-II, a validated instrument that measures interprofessional collaboration. We analyzed individual paired differences in summary scores and in each of three subdomains of the AITCS-II questionnaire: partnership, cooperation, and coordination. Seventeen teams completed the AITCS-II post survey, representing 133 participants. Teams varied demographically and ranged from 5 to 16 members. After CAPACITI, the overall mean AITCS-II summary score among teams increased to 96.0 (SD = 10.0) for a significant paired mean difference increase of 9.4 (p = .03). There were also significant increases in the partnership (p = .01) and in the cooperation subdomains (p = .04). CAPACITI demonstrated the potential for improving collaboration among primary care teams, which can lead to improved provider and patient outcomes in palliative care.

Factors Impacting Retention of Aged Care Workers: A Systematic Review

Retention of care support workers in residential aged care facilities and home-based, domiciliary aged care is a global challenge, with rapid turnover, low job satisfaction, and poorly defined career pathways. A mixed-methods systematic review of the workforce literature was conducted to understand the factors that attract and retain care staff across the aged care workforce. The search yielded 49 studies. Three studies tested education and training interventions with the aim of boosting workforce retention and the remaining 46 studies explored opinions and experiences of care workers in 20 quantitative, four mixed-methods and 22 qualitative studies. A range of factors impacted retention of aged care staff. Two broad themes emerged from the analysis: individual and organisational factors facilitating retention. Individual factors related to personal satisfaction with the role, positive relationships with other staff, families, and residents, and a cooperative workplace culture. Organisational factors included opportunities for on-the-job training and career development, appropriate wages, policies to prevent workplace injuries, and job stability. Understaffing was often cited as a factor associated with turnover, together with heavy workloads, stress, and low job satisfaction. With global concerns about the safety and quality of aged care services, this study presents the data associated with best practice for retaining aged care workers.

Communication Disparities between Nursing Home Team Members

Optimal care in nursing home (NH) settings requires effective team communication. Certified nursing assistants (CNAs) interact with nursing home residents frequently, but the extent to which CNAs feel their input is valued by other team members is not known. We conducted a cross-sectional study in which we administered a communication survey within 20 Utah nursing home facilities to 650 team members, including 124 nurses and 264 CNAs. Respondents used a 4-point scale to indicate the extent to which their input is valued by other team members when reporting their concerns about nursing home residents. We used a one-way ANOVA with a Bonferroni correction. When compared to nurses, CNAs felt less valued (CNA mean = 2.14, nurse mean = 3.24; p < 0.001) when reporting to physicians, and less valued (CNA mean = 1.66, nurse mean = 2.71; p < 0.001) when reporting to pharmacists. CNAs did not feel less valued than nurses (CNA mean = 3.43, nurse mean = 3.37; p = 0.25) when reporting to other nurses. Our findings demonstrate that CNAs feel their input is not valued outside of nursing, which could impact resident care. Additional research is needed to understand the reasons for this perception and to design educational interventions to improve the culture of communication in nursing home settings.