The relationship between registered nurses and nursing home quality: an integrative review (2008-2014).
This integrative review is unique in that the RN is the sole focus of the review. By virtue of education and training, the RN is a key contributor to NH quality (Castle & Anderson, 2011; IOM, 2004). Researchers have reported a positive relationship between RN involvement in decision making and better clinical outcomes (Anderson & McDaniel, 1992, 1998, 1999). This is significant because effective care planning is based on the quality of clinical decision making (Centers for Medicare & Medicaid Services [CMS], 2013). Skills in care plan development, care planning, and coordination of care with interdisciplinary team members are codified as core RN competencies within RN state practice acts in the United States (American Nurses Association, 2010).
No prior review has examined the RN as a key contributor to the NH; yet research highlights the multifaceted role of the RN in NHs and their positive impact on residents, relatives, and staff (Heath, 2010). This review of research findings is made in an effort to advance the evidence-base supporting the proposition that RNs add value to NH residents' experiences both directly through the level of RN staffing and indirectly through the clinical leadership they provide to members of the nursing skill mix.
Over the past 18 years, three IOM reports have focused on nursing home quality. The 1986 report contained recommendations for fundamental changes in the federal government's oversight of NH care. Although specific RN staffing levels or nursing skill mix ratios were not proposed, the essential responsibility of professional and competent NH management (e.g., director of nursing [DON]), to create a positive work environment was emphasized (IOM, 1986). A review of studies summarizing the evidence base for a relationship-oriented management practice in NHs provides recent empirical support of this original recommendation (Toles & Anderson, 2011).
While the complexity of factors influencing achievement of quality services in NHs was acknowledged in a 1996 IOM report, specific recommendations for RN staffing were made. Committee members recommended that, by the year 2000, Congress would require a 24-hour presence of RN coverage; the use of geriatric nurse specialists and geriatric nurse practitioners hired in leadership and direct-care positions; a more structured approach to training of NAs; and greater emphasis placed on the educational preparation of new DONs (IOM, 1996).
Similar RN staffing recommendations were made in a 2004 IOM report. The authors recommended greater input of direct-care nursing staff into operational decisions (e.g., nurse staffing levels, skill mix, a redesign of work processes, and workflow to promote safety outcomes); study of factors contributing to nursing turnover; the 24-hour presence of at least one RN within a NH at all times; and implementation of staffing levels recommended in the Department of Health and Human Services (DHHS) report to Congress, "Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes" (IOM, 2004).
However, few IOM recommendations or those of an expert panel on nursing home culture (Burger et al., 2009) have become federal law, with one exception (Harrington et al., 2000). Since the passage of the Nursing Home Reform Act included in the 1987 Omnibus Budget Reconciliation Act, a RN has been required to either conduct or coordinate the completion of the Resident Assessment Instrument.
Currently, federal requirements for RN staffing in NHs remain low, even though resident acuity and complexity have increased substantially (Hirdes, Mitchell, Maxwell, & White, 2011). A facility is required to employ a RN as a DON. At least one RN must be on duty for no fewer than 8 hours per day, 7 days a week. In facilities with fewer than 60 residents, the DON may serve as the one RN on duty. Consequently, no requirement exists for facilities of 100 beds or more to employ an assistant DON or director of education. On evening and night shifts either an RN, LPN, or LVN is required (IOM, 2004). The national average of RN hours per resident day (HPRD) in 2014 was 0.47; the national average of direct-care staff horns per patient day in 2014 was 3.73 (American Health Care Association, 2014). These figures are in stark contrast to RN staffing in hospitals of over 10 horns per patient in a 24-hour period (Welton, 2007).
In the past 8 years, 10 literature or systematic reviews addressing extant NH quality and all nursing staffing levels and practices have been published (Backhaus, Verbeek, van Rossum, Capezuti, & Hamers, 2014; Bostick, Rantz, Flesner, & Riggs, 2006; Bryan et al. 2010; Castle, 2008a; Collier & Harrington, 2008; Dongjuan, Kane, & Shamliyan, 2013; Hodgkinson, Haesler, Nay, O'Donnell, & McAuliffe, 2011; Shin & Bae, 2012; Spilsbury, Hewitt, Stirk, & Bowwan, 2011; Streak, 2011). Findings have ranged from "a proven association between higher total staffing levels (especially licensed staff) and improved quality of care" (Bostick et al., 2006, p. 366) to "no consistent evidence found for a positive relationship between staffing and quality of care" (Backaus et al., 2014, p. 383). This disparity is largely based on differing assessments of the scientific rigor of the studies reviewed (Castle, 2008a; Spilsbury et al., 2011).
Search strategy. Combinations of key terms were used including registered nurse, nursing home, quality, nursing skill mix, RN scope of practice, quality of life, quality of care, deficiency citations, nurse staffing, work environment, and Minimum Data Set (MDS). Research studies and literature published in English between 2008 and 2014 were searched. Advanced practice nurse was excluded as a key term because the focus of this review was on the relationship of RNs practicing in the roles of DON, charge nurse, supervisor, MDS RN coordinator, clinical RN, and NH quality. While there is evidence use of advanced practice nurses has been associated with improved quality (e.g., reduction in avoidable rehospitalizations from NHs to acute hospitals), the authors believe it is important to focus on the RN staff infrastructure that exists in the majority of NHs (Boyd et al., 2014).
Searches included several databases: Cochrane Library, CINAHL, Pubmed, PsychINFO, Ovid, Google Scholar, and grey literature (e.g., government websites, reports, and texts). A total of 16,000 references were identified through database searching. Thirty-one records were identified in the grey literature. Duplicate citations were removed; the remaining 1,300 citations were reviewed and crosschecked with references used in selected literature reviews/systematic reviews (e.g., Backaus et al., 2014; Castle, 2008a; Collier & Harrington, 2008; Spilsbury et al., 2011). Any study previously cited in a review was removed from the search list to avoid duplication in reporting study findings; 175 full abstracts were reviewed, of which 133 full articles were printed. Sixty-six full texts were removed for a range of reasons (e.g., tool development, not including and/or reporting RN staffing levels, RN sample size, the individual numbers of RN and LPN/LVNs included in "licensed nurses" as a study variable, or failure to report RN-specific findings). Sixty-seven studies remained and were included in the review. This process is shown in Figure 1.
Characteristics of studies reviewed. The 67 studies reviewed used various types of designs: cross-sectional (n=33), mixed methods (n=3), longitudinal (n=13), qualitative (n=10), descriptive (n-6), and cohort (n=2) designs. Nursing homes or aged-care facilities representing six nations were included: United States (n=60), Canada (n=4), United Kingdom (n=2), Germany (n=1), Norway (n=1), and Sweden (n=1). The unit of analysis used in studies included nursing home administrators, RN roles (DON, RN MDS coordinator, charge or supervisory RN, and clinical RN), residents, NHs, and observational units (e.g., surveys, quarterly MDS assessments). Sample sizes varied widely including ranges of NHs sampled (1 to 11,611), residents (1,376 to 692,875), nursing home administrators (419 to 2,900), RNs employed in various roles (16 to 1,048), observational units (4,476 to 148,900), and 50 RN and LPN/LVN state practice acts and scopes of practice. In comparison with previously published reviews, there was an increase in the number of studies reviewed that focused on the impact of state and federal policies on minimal nurse staffing standards and RN staffing (n=8); used longitudinal designs (n=13) and qualitative and mixed methods (n=12); included the work environment or organizational culture as variables (n=6); and non-U.S. NHs (n=5).
Variables and measures of quality indicators and work environment. Most variables and measures of quality indicators were similar to those used in earlier reviews as shown in Tables 29. They included structural and process quality indicators; resident and employee outcomes; case mix, facility, and market variables; and the impact of policy changes (e.g., changes in federal or state minimum staffing levels and reimbursement rates). In recent years, researchers have included variables measuring the work environment and safety culture as shown in Table 5.
Data sources. Data sources used were similar to those used in earlier literature reviews and systematic studies (a summary of reviewed studies is available from the authors upon request). They included the Area Resource Files fn=15), MDS data other than quality indicators or quality measures (n=13), On-line Survey Certification and Reporting [OSCAR] (n=33), primary data (e.g., surveys, focus groups, interviews, direct observation, field notes) (n=32), quality indicators or measures from Nursing Home Compare (n=10), Automated Certification and Licensing Administrative Information Management Systems (n=l), or other sources.
Conceptual frameworks. Conceptual frameworks used to provide support for hypothesized relationships among key concepts and constructs related to RNs and NH quality were diverse. Donabedian's quality framework (Donabedian, 1992), complexity theory (Corazzini et ah, 2014), and Castle and Engberg's (2008) conceptual model were used most frequently (see Table 1). These frameworks reflect the complexity of factors influencing subjective and objective definitions and measurement of NH quality. These include factors such as nurse staffing level, nurse skill mix, ownership (e.g., structural); perceptions of teamwork, mutual respect, and open communication (e.g., process); and prevalence of pressure ulcers, urinary tract infections, falls, and deficiency citations (e.g., outcomes).
Structural quality indicators. Structural indicators of quality are stable characteristics, such as nurse staffing levels, resident clinical conditions, and facility demographics, such as ownership and size. Structural measures used to study the association of RNs and quality in NHs varied, as shown in Table 2 (agency RNs, RN staffing hours, nursing skill mix, professional jurisdiction, and RN retention intrinsic and extrinsic factors). Some resident characteristics were measured using case mix or acuity measures as shown in Table 6. Measurements for facility characteristics are shown in Table 7.
Registered nurse staffing continued to be measured in a variety of ways, with RN hours per resident day being the most frequently used (19 studies). Castle and Engberg (2008) and Castle (2009) measured agency RN (see Table 2).
Nursing skill mix was measured in 11 different ways (see Table 2). The two most frequently used measures were "number of RNs" and the "ratio of RNs to the sum of LPNs/LVNs and NA staff."
Process quality indicators. Process quality indicators are used to measure how care, or nursing work, is performed to produce experiences for residents and NH staff. Care processes used will differ based on resident characteristics, acuity, length of stay, and types and numbers of nursing staff included in the nursing skill mix. Care processes may be of a technical and directly observable nature, or of an interpersonal nature that requires both qualitative and quantitative methods to measure comprehensively. Measurement of relationships between RNs and their team members, or RNs and resident relationships, despite their profound influence on residents' quality of care, are not as easily measured (McGilton et al., 2012; Spilsbury et al., 2011). Because of this, they were not frequently included in studies (see Table 3).
Outcome quality indicators. The most frequently used outcome measures were those contained in government databases, including deficiency citations of various types from the OSCAR database (n=18), long-stay (n=25) and short-stay (n=9) quality measures derived from MDS data, other MDS-derived measures (n=4), and incidence or prevalence of pressure ulcers (n=5). Employee outcomes measured included turnover (n=7), retention (n=6), and RN intention to leave (n=l), intention to stay (n=l), and job satisfaction (n=l). Other outcome measures were derived from primary data (data observed or collected directly) (n=5) or Medicare databases (n=5).
Other characteristics associated with NH quality. The relationship of RNs and NH quality is complex, in part because many other macro and micro-system level variables exert an influence (see Tables 5-9). Examples included case-mix characteristics of residents, some of which are mutable or immutable, facility-level factors, market characteristics, the impact of legislative changes in NH staffing levels, state Medicaid rates, Medicare reimbursement rates, and geographic locations of facilities.
Findings of the relationship between RNs and NH quality. In studies using quantitative methods, higher RN staffing was associated with better resident care quality where the following indicators were examined: fewer pressure ulcers, better quality measures, lower restraint use, decreased probability of hospitalization, fewer deficiency citations, decreased mortality, and decreased incidence of urinary tract infections. Higher RN staffing was associated with better employee outcomes where lower NA and RN turnover were examined.
In NHs having a higher RN ratio to other nursing staff, the higher professional skill mix was associated with lower restraint use, perceived risk of malpractice losses, fewer dually eligible Medicare beneficiaries discharged to SNFs, licensed nurses spending more time with residents, and NHs with high Medicaid census. Less DON turnover was positively associated with lower levels of education, higher job satisfaction, lower nursing staff turnover, and increased NH occupancy. As shown in Table 5 in studies that examined the relationship between a better work environment, care processes, and outcomes, the following indicators were used: lower pressure ulcer rate, lower restraint use, having an administrator with a consensus leadership style, higher hierarchical values held in the NH, lower intent to leave, higher job satisfaction, and NHs with higher capacity for RN jurisdiction. Findings reported from studies using qualitative methods described RNs as negatively influenced by unsupportive work environments, poor leadership, low levels of teamwork and clinical leadership, poor communication, difficult relationships between members of the nursing skill mix, and greater organizational emphasis on compliance rather than quality.
The impact of changes in reimbursement rates and minimum staffing requirements on RN staffing, skill mix, and care quality were mixed (see Table 9). For example, Mukamel, Kang, Collier, and Harrington (2012) found a positive impact of anticipated changes in reimbursement rates and RN staffing levels. In contrast, others found negative or insignificant impacts. For example, Feng, Grabowski, Intrator, Zinn, and Mor (2008) reported that changes in state Medicaid rates and case-mix reimbursement in 48 states were associated with decreased RN HPRD. In another study, Feng and colleagues (2010) found no wage pass-through effect for RN HPRD. Chen and Grabowski (2014) reported that, although fewer RNs were fired relative to NAs, no significant changes in quality measures (Medicare-defined measures of the quality of care), other than contractures, and a reduction in severe deficiencies with minimum staffing regulations in California and Ohio were found.
Prior reviews identified several limitations in the research literature, including concern about data quality and accuracy, lack of standardized measurements of variables, a need for larger sample sizes, greater use of mixed methods and longitudinal designs, greater focus on nursing skill mix, and employee outcomes. While issues remain about data quality and lack of standardization of measurements, this review shows progress has been made in increasing the number of studies using larger sample sizes, qualitative and mixed methods, longitudinal designs, and measurement of the work environment and safety culture.
Most of the studies included in this review consistently reported higher RN staffing and higher ratios of RNs in the nursing skill mix are related to better NH quality. The strongest evidence supporting a causal relationship between higher RN staffing levels, higher RN ratios within the nursing skill mix, and quality indicators is found in several longitudinal studies (Castle & Anderson, 2011; Castle, Wagner, Ferguson, & Handler, 2014; Castle, Wagner, Ferguson-Rome, Men, & Handler, 2011; Kim, Harrington, & Greene, 2009; Konetzka, Steams, & Park, 2008; Lin, 2014), and the cohort study findings of Spector, Limcangco, Williams, Rhodes, and Hurd (2013). Given that a controlled experiment on RN HPRD and outcomes is not feasible or ethical, alternative methods must be found to more rigorously determine the causality of the relationship between increased RN staffing and increased NH quality. For example, Lin (2014) used the method of instrumental variables to estimate a causal relationship between increased RN HPRD and quality. Instrumental variables are used to address measurement problems, including omitted variable bias, measurement error, simultaneity, or reverse causality (Staiger & Stock, 1997). Lin noted no significant relationships were found between the RN HPRD and quality outcomes when the more common ordinary least squares regression model was used.
Some study findings were unexpected, and provide evidence of the challenges gerontological nurse educators and leaders face in increasing the skills of RNs currently working in NHs. For example, Castle and Engberg (2008a, 2008b) found that increased use of agency RNs was associated with higher quality. They suggested the clinical skill level of the agency RNs may be higher than that of the regular RNs included in the study sample. Directors of nursing with higher levels of education have shorter tenure (Decker & Castle, 2009).
Taken together, these findings suggest RNs practicing in NHs may be less well prepared clinically. This is consistent with the fact most RNs and DONs practicing in NHs have only an associate's degree or diploma-level education (IOM, 2004). The need for DONs and more RNs practicing in NHs to have a baccalaureate education is clear (Siegel et al., 2012). While the potential is there for RNs to have a significant impact on the quality of NH care, the NH tends to be a less-attractive career choice than other practice settings to many RNs. The nature of the nursing skill mix used, and its implications for RN practice, may contribute to this.
Gerontological nurse leaders and educators are therefore challenged to find ways to serve as educational resources to NHs. Evidence-based best practices known to enhance NH RN staff competencies exist (Bourbonneiere & Strumpf, 2008). Promising programs include peer mentoring, training to develop DON'S coaching and person-centered management skills, better orientation programs, and advanced practice nurse consultant visits to NHs (McGilton et al., 2012).
However, given no federal requirement exists for RNs to have specialized education in gerontological nursing upon hire and throughout their NH employment, it is likely concerns about cost will restrict the NH industry from widely embracing such programs. As initially highlighted, NH care is expensive; second only to acute hospital care for inpatient Medicare costs (OIG, 2014). Therefore, concerns about the costs of employing more highly skilled RNs and DONs who have the potential to positively influence members of the nursing skill mix will continue to influence NH industry hiring practices. Findings from studies that measured the impact of minimum state staffing requirements and changes in Medicaid and reimbursement rates demonstrate this concept.
Legislation has recently been passed that should greatly enhance the quality of CMS NH data often used by NH researchers. A provision in the recently signed Improving Post Acute Care Transformation Act of
2014 (IMPACT) has the potential to improve the accuracy of the reporting of muse staffing levels, skill mix, and turnover data in NHs significantly. CMS is to implement quarterly electronic reporting of NH staffing information by the end of fiscal year 2016 that is auditable (PHI, 2014).
Studies that build on the work of researchers who have used conceptual frameworks that mirror the complexity of the NH practice environment are recommended. Examples of these include the adaptive leadership framework derived from complexity theory (Corazzini et al., 2014), Castle and Engberg's framework (2008), and Donabedian's (1992) quality framework. For example, Corazzini and colleagues (2014) used complexity theory to describe how adaptive leadership and technical practices are needed in the increasingly complex and dynamic NH practice environment if greater NH quality is to be achieved. Adaptive leadership, an approach believed to foster work environments supportive of person-centered care, emphasizes flexibility, rather than rigidity, in providing care that is responsive to resident preferences and values. Adaptive leadership, based on complexity theory, is a promising framework to use for further research of clinical supervision that is person-centered. Finally, researchers need to increase the use of economic frameworks to study the benefits of increasing the number and qualifications of RNs working in NHs with respect to costs and quality.
Continued use of mixed methods to study RN NH work is recommended. This approach increases the ability to more fully understand the directly observable and unobservable cognitive work of the RN, members of the nursing skill mix (IOM, 2004), and their interactions with one another that likely differ as RN staffing levels and the composition of the nursing skill mix varies. For example, a mixed methods approach is ideal for better understanding the mechanisms by which RNs add value to the nursing skill mix and enhance the resident's NH experience.
Two important mechanisms are nursing surveillance, or patient monitoring and coaching/person-centered supervision and management. Surveillance is defined as the ongoing acquisition, interpretation, and synthesis of clinical data for clinical decision making (IOM, 2004). It is different from assessment; it is an intervention that occurs over time, rather than a single point in time. Framed another way, surveillance involves visible and invisible care activities of the RN, or any nursing staff (IOM, 2004). Resident surveillance is used in providing both direct (nursing assessment, physical care, administration of treatments, and psychological care) and indirect care (documentation, supervision, management, and other activities performed away from residents but on their behalf to coordinate and manage the care experience and environment) (Dellcfield, Harrington, & Kelly, 2012).
Given the likelihood the RN presence in NHs will continue to be relatively limited, and most care will be provided by paraprofessionals, greater understanding of how nursing care delivery systems may increase their surveillance capacity is recommended. This is an urgent need given poor resident monitoring was cited as one of the three practices responsible for the preventable adverse events studied in the 2014 OIG report on Medicare beneficiaries.
Conducting research on the relationship of RNs and NH quality must continue, in spite of the persistent methodological challenges presented to researchers. For both the advancement of nursing as an applied science and the benefit of society at large, nursing researchers are challenged to better demonstrate how the increased presence of a registered nurse on each shift has the potential to enhance the cost effectiveness, efficiency, and quality of nursing homes. Nurse faculty and leaders are challenged to find ways that help nursing students recognize RN practice in a NH as complex, challenging, and a setting in which NH residents will benefit on both an individual and system level from their presence.
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MARY ELLEN DELLEFIELD, PhD, RN, is Research Nurse Scientist, VA San Diego Healthcare System (VASDHS), San Diego, CA.
NICKOLAS G. CASTLE, PhD, MHA, is Professor, Department of Health Policy & Management, University of Pittsburgh, Pittsburgh, PA.
KATHERINE S. McGILTON, PhD, RN, is Associate Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
KAREN SPILSBURY, PhD, RN, is Professor, Department of Health Sciences, University of York, Heslington, York, United Kingdom.
NOTE; The views expressed in this article are those of the authors, and not necessarily those of the Veterans Health Administration.
Table 1. Summary of Conceptual Frameworks/Models Used in Reviewed Studies of the Relationship of RNs and NH Quality Number of Framework/Model Studies Castle and Engberg Staffing Framework 2 Competing Values Framework 1 Complexity Theory/Science/Complex Adaptive Systems 4 Donabedian's Quality Framework 7 Flerzberg, Mausner, Snyderman Concepts of Intrinsic 1 Motivation, Self-Growth, Job Satisfaction High-Reliability Organizations (Mindfulness) 1 McGilton, Bowers, Boscart Model of Intention to Stay 1 among Nurses in Long-Term Care Work Environment Nursing Organization and Outcomes Model 2 Organizational Culture (Safety Culture) 2 Professional Jurisdiction 1 Random Utility Maximization Model 1 Resource-Based Organizational Theory 1 Standard Economics Model 2 Stressors and Workplace Support Model of Turnover 1 Theory of Chain Growth 1 Theory of Planned Behavior 1 Turnover Theories 2 Table 2. Summary of Structural Quality Indicators Used in Reviewed Studies of the Relationship of RNs and NH Quality Number of Variable Specific Measure Studies Agency RNs Agency registered nurses (RNs) as 2 percentage of all RNs all facilities or only facilities using agency staff Full-time equivalent (FTE) agency 1 RNs/100 beds RN agency (number RNs used in past year 1 as percent of regular staff) RN agency staff 1 RN Staffing RN hours per resident day (HPRD) 19 Hours FTE RNs/100 residents 6 FTE RNs/resident 3 FTE RNs 3 RN daily hours/bed 2 RN HPRD = RNs + directors of nursing 1 (DON) RN productive hours (full and part-time, 1 temporary) RN hours/resident 1 Nursing Skill FTE RNs/total nurses 1 Mix Licensed staff (RN + licensed practical 1 nurse [LPN]) as percent of total nursing staff Percent RNs of total nursing staff 1 RN FTEs/LPNs + nursing assistants (NAs) 1 full-time, part-time, and temporary included RN FTEs/RN + LPN + NA FTEs 1 FTE RNs full time in permanent 1 positions/total number of workers (including unfilled positions) RN/LPNs + NAs 5 Number RNs 4 Percent RNs 1 RN staffing hours as proportion of total 3 staffing hours RN HPRD/LPN HPRD 1 Professional DON prepared at BSN level; other RNs in 1 Jurisdiction facility prepared at BSN level; specialty certification of DON; specialty certification of other RNs in facility; RNs in facility have graduate degree; presence of APNs in facility; proportion of nursing staff that are RNs RN Retention Flexible scheduling, paid personal day, 1 Extrinsic retirement, paid sick days, health Factors insurance, Alzheimer's unit, parenteral nutrition services, nursing HPRD, administrator tenure in months, DON tenure in months, RN wage ratio RN Retention Recognition, conference money, attendance 1 Intrinsic awards, career ladder, tuition money, Factors career development Table 3. Summary of Process Quality Indicators Used in Reviewed Studies of the Relationship of RNs and NH Quality Number of Variable Specific Measure Studies Antipsychotic Percent of residents receiving 2 Drug Use antipsychotic drugs Consistent Same caregivers consistently caring for 2 Assignment the same resident almost every time they are on duty Leadership Four-item Nurse Manager Ability, 1 Relationships Leadership, and Support of Nurses subscale of the Revised Nursing Work Index (NWI-R) Long-Stay Percentage of; Quality Measures Residents with increased need for help 1 with daily activities Residents with physical restraint use 2 Residents who had a catheter inserted and 5 left in bladder RN Care Average RN direct care time/resident day 7 Activity Percent of RN time engaged in specific 1 type of care activity Resident Six-item support relations subscale of 2 Relationships Person-Directed Care Scale (PDCS) Work Work Group Cohesion Scale 1 Relationships Work Group Identification Scale (WGIS) 1 Table 4. Summary of Outcome Quality Indicators Used in Reviewed Studies of the Relationship of RNs and NH Quality Number of Variable Specific Measure Studies All-Cause Mortality and Resident mortality/ 1 Hospitalization hospitalization occurred during outbreak period compared with non-outbreak period of reported norovirus in nursing homes Burnout Nine-item emotional 1 exhaustion subscale of Maslach Burnout Inventory (MBI) Contractures Percent of residents with 1 contractures Deficiency Citations Health deficiencies found 1 during the inspection; 100 per resident Life and safety 1 deficiencies found during the inspection; 100 per patient Quality of care 1 deficiencies Sum of numeric scores for 1 each deficiency Total deficiencies found 1 during the inspection; 100 per resident Deficiency Citation for F-Tag 444 (staff hand 1 Hand Hygiene washing after direct resident contact) Deficiency Citation for F-Tag 441 (the facility 1 Infection Control must establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection) Deficiency Citations for F-Tag F221 and F323 1 Physical Restrains and combined Restrictive Side Rails Hospitalization Risk Ambulatory care-sensitive 1 conditions (ACSCs); additional NH-sensitive avoidable conditions (ANHACs); NH "unavoidable" conditions (NHUCs) Incontinence Proportion of residents 1 with incontinence without toileting plan Intention to Leave DON intention to leave (12 1 and 24 months) Intention to Stay Self-report of likelihood 1 of staying at facility for next 5 years Job Satisfaction Job Satisfaction Scale 1 (MMSS) Leadership Style Jerrel-Slevin management 1 instrument Long-Stay Quality Measures Percentage of: High-risk residents with 4 pressure ulcers Low-risk residents with 3 pressure ulcers Low-risk residents with 2 loss of bladder or bowel control Residents who spent most of 3 their time in bed or in a chair Residents with urinary 4 tract infection Residents with 4 moderate-to-severe pain Residents more anxious and 2 depressed Residents with decreasing 3 ability to move in/around room Average number of 1 complaints per nursing home per quarter Number complaints from 1 division of health service regulation Malpractice Paid Losses Malpractice paid losses or 1 no malpractice paid losses Nursing Home Complaints Number of complaints in 1 North Carolina Pressure Sores Number of residents with 1 pressure sore within last 14 days Percent of residents with 2 pressure sores Incidence of pressure sores 2 Quality of Life Section F Minimum Data Set 2 3.0 Six domains: environment, 1 personal attention, food enjoyment, engagement, negative mood, positive mood Reason for Discharge Percentage of residents 2 Comparing Hospitalization hospitalized, recovered/ or Nonhospitalization stabilized died in nursing Prior to Nursing Home home, discharged to another Admission long-term care setting, or other setting RN Satisfaction Nine-item scale (Aiken, 1 Clarke, Sloane, Lake, & Cheney, 2008) RN Retention RN staff employed during 1 the period, not including DON or agency Total number RNs employed 1 over 10-month period 2010 Mean tenure of DON 1 Serious Deficiencies G or higher level of 4 deficiency Short-Stay Quality Percentage of residents 2 Measures with delirium Percentage who had 2 moderate-to-severe pain Percentage with pressure 2 ulcers Lost too much weight 3 malpractice claims Threat of Litigation Lagged 2-year moving 1 average of the county-level number of total deficiency citations Total Defiency Citations 6 RN Turnover Administrator self-report 1 of RN turnover Administrator self-report 1 of voluntary and involuntary turnover (percent RNs leaving nursing home within 6 and 12 months) Percent FTE RN turnover in 1 2007; staff who left employment during past quarter/total number Percent FTE RN turnover in 1 past quarter; (total number of RN turnover (departure for 1 year as percentage of total nursing positions) Administrator self-report 1 of percent RNs employed more than 1 year Number of regulated nurses 1 who terminated employment over the past 12 months/ total number of nurse FTEs employed RN stability (percent RNs 1 who worked 5 years or more) Urinary Tract Infection Urinary tract infection 1 within last 30 days Workplace Injuries Lost days away from work 1 (including cases away from work and cases with only restricted work activity) Table 5. Summary of Contextual Characteristics Used in Reviewed Studies of the Relationship of RNs and NH Quality Number of Variable Specific Measure Studies Competing Values Measure Competing Values Framework 1 question related to group culture, developmental culture, market culture, hierarchical culture Nursing Home Work Staff cohesion; self-managed 1 Environment teams; formal teams; consistent assignment Perceived Patient Safety Average percent positive 2 Culture score for the 12 domains of the Nursing Home Survey on Patient Safety Culture (NHSPSC) Practice Environment Practice Environment Scale of 2 the Nursing Work Index (PES-NWI) Table 6. Summary of Case Mix/Resident Acuity Characteristics Used in Reviewed Studies of the Relationship of RNs and NH Quality Number of Variable Specific Measure Studies Acuity Index OSCAR data for a range of ADL 2 dependencies and special treatment measures for all residents Average Score for Three Give score of 1 for low need 4 ADLs for assistance with ADLs, 2 for moderate assistance, and 3 for high need for assistance with ADLs Case Mix Average ADL dependency score 1 of residents in three ADLs (eating toileting, transferring to and from bed) and percent of new cognitively impaired residents Number of residents in the 1 nursing home who can perform ADLs independently High ADL dependence 1 ADL index, special care index, 1 percent residents on admission having pressure ulcer, and contractures; percent depressed with psychiatric diagnosis and dementia Late loss ADLs and Cognitive 1 Performance Scale Composite of ADLs and average 1 Texas Index of Level of Effort CMS composite score based on 1 all residents Resource utilization group 1 (RUG) classifications converted to numbers; 23 categories with each group used as a control variable Percent of residents with 1 pressure sores, contractures, and restraints on admission Physical case mix (ACUINDEX 1 and percent of residents who are bed and chair bound) + mental health case mix (percent of residents with dementia, depression, psychiatric illness other than dementia, and developmental disability) Cowles Acuity Index Staffing HPRD/ACUINDEX [The 4 weighted sum of proportion of residents with need for special treatment (STINDEX) and dependencies in ADLs (ADLINDEX)] Level of ADL Dependence High ADL dependence for a 1 resident needing assistance with all three ADLs (bathing, dressing, eating) or required assistance transferring in and out of chair Limited ADL Index Proportion of residents with 1 ADL limitations in four areas (toileting, transferring, incontinence, eating) Measure of Resident Need Percent Medicare residents/ 1 total residents + number of medications and catheters/ resident + number of pressure ulcers + ADL needs/resident Number of residents with 1 limitations in ADLs RUGS III RUGs case mix index derived 1 from Minimum State Set data Resident Acuity Weighted sum of ADL index and 1 special treatment index Percent residents with 1 limitations in ADLs and percent receiving rehabilitation Resident Care Needs Facility average case mix 1 score No Case Mix Reported in 30 Studies Using Mix of Quantitative Methods Table 7. Summary of Facility Characteristics Used in Reviewed Studies of the Relationship of RNs and NH Quality Number of Variable Studies Average Census 3 Average Length of Stay 2 Facility Size 2 Large = more than 150 beds; medium = 50-150 beds; small = less than 50 beds Gender/Ethnicity of Residents Percent residents who are male 1 Percent residents who are Black 2 Percent residents who are Hispanic 1 Location in Hospital 6 Medicaid Reimbursement Rate 16 Medicaid Bed Hold Policy 1 Medicare Reimbursement Rate 1 Membership in Chain 29 Occupancy Rate 22 Ownership For-profit, not-for-profit, governmental 39 Ownership Change 1 Private Paid Days 1 Payer Mix Percent Medicare residents 21 Percent Medicaid residents 30 Percent private pay 12 Medicare paid days 1 Medicaid paid days 1 Presence Nurse Practitioner/Physician Assistant 3 Rural Location 1 Specialty Unit/Program 5 Total Beds 30 Urban Location 5 Table 8. Summary of Market Characteristics Used in Reviewed Studies of the Relationship of RNs and NH Quality Number of Variable Specific Measure Studies Market Average income (log) 1 Average per capita income 10 Competitiveness of RN wage 1 County unemployment rate 5 Percent poor in market 2 Female employment rate 3 Hospital wage index 6 Herfindahl-Hirschman Index 15 Medicare managed care 3 penetration rate Weekly wages 1 Bed Supply Number of nursing homes in 4 county Average number of empty beds in 9 market Number of nursing home 2 beds/1,000 elderly Excess nursing home beds 1 Elderly Population Number of elderly in county 4 Population aged 85 years and 3 older Size of senior population (log) 1 Population density 2 Healthcare Workforce Physicians per 1,000 persons 65 1 years and older Number of RNs in 1,000 1 Population Table 9. Summary of Policy Change Characteristics Used in Reviewed Studies of the Relationship of RNs and NH Quality Number of Variable Specific Measure Studies Impact of California Medicaid payment rate in 1 Medicaid Reimbursement for 2008 calculated by state Nursing Homes for each facility State Medicaid Wage Medicaid wage pass-through 1 Pass-Through to nursing homes variable with baseline: pre-adoption; year of adoption; first year after adoption (with policy still in effect); second or subsequent years after adoption (with policy still in effect); and policy repealed Medicaid Nursing Home Annual state-average 1 Reimbursement Medicaid per diem rate, inflation-adjusted to 2004 dollars Use of case-mix payment 1 system in a given state and year California law specifying minimum nurse staffing requirements Minimum Staffing Standards California law specifying 2 minimum nurse staffing requirements As total direct-care hours with same weight to RN, LPN, and certified nursing assistant (CNA) hours Ohio law specifying minimum 1 nurse staffing requirements as total direct-care hours with same weight to RN, LPN, and CNA hours Changes made between 1998 1 and 2001 in 16 states to implement or expand staffing standards in excess of federal requirements
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|Author:||Dellefield, Mary Ellen; Castle, Nickolas G.; McGilton, Katherine S.; Spilsbury, Karen|
|Date:||Mar 1, 2015|
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