Abstract
BackgroundDefining what constitutes a resident care unit in nursing home research is both a conceptual and practical challenge. The aim of this paper is to provide evidence in support of a definition of care unit in nursing homes by demonstrating: (1) its feasibility for use in data collection, (2) the acceptability of aggregating individual responses to the unit level, and (3) the benefit of including unit level data in explanatory models.MethodsAn observational study design was used. Research (project) managers, healthcare aides, care managers, nursing home administrators and directors of care from thirty-six nursing homes in the Canadian prairie provinces of Alberta, Saskatchewan and Manitoba provided data for the study. A definition of care unit was developed and applied in data collection and analyses. A debriefing session was held with research managers to investigate their experiences with using the care unit definition. In addition, survey responses from 1258 healthcare aides in 25 of the 36 nursing homes in the study, that had more than one care unit, were analyzed using a multi-level modeling approach. Trained field workers administered the Alberta Context Tool (ACT), a 58-item self-report survey reflecting 10 organizational context concepts, to healthcare aides using computer assisted personal interviews. To assess the appropriateness of obtaining unit level scores, we assessed aggregation statistics (ICC(1), ICC(2), η2, and ω2), and to assess the value of using the definition of unit in explanatory models, we performed multi-level modeling.ResultsIn 10 of the 36 nursing homes, the care unit definition developed was used to align the survey data (for analytic purposes) to specific care units as designated by our definition, from that reported by the facility administrator. The aggregation statistics supported aggregating the healthcare aide responses on the ACT to the realigned unit level. Findings from the multi-level modeling further supported unit level aggregation. A significantly higher percentage of variance was explained in the ACT concepts at the unit level compared to the individual and/or nursing home levels.ConclusionsThe statistical results support the use of our definition of care unit in nursing home research in the Canadian prairie provinces. Beyond research convenience however, the results also support the resident unit as an important Clinical Microsystem to which future interventions designed to improve resident quality of care and staff (healthcare aide) worklife should be targeted.
Highlights
Defining what constitutes a resident care unit in nursing home research is both a conceptual and practical challenge
In this paper we describe the process by which we reached a practical definition of unit in the nursing home context, and provide practical and statistical evidence that supports its use in health services research and its potential use in quality improvement activity in nursing homes
The number and names of units were required for programming the software for the computer-assisted personal interviews (CAPI) interviews with the healthcare aides and for sampling, which was based on percentages of eligible aides by unit
Summary
Defining what constitutes a resident care unit in nursing home research is both a conceptual and practical challenge. Defining a unit can be a conceptual and practical challenge for researchers interested in studying the influence of clinical units on patient and resident outcomes. These clinical units are embedded in the organizational chart, as the de facto elementary structures of a healthcare organization. These operating units with varying coordination mechanisms co-exist with formal structural boundaries. All of these features point to the need for a mutually agreed upon definition of ‘unit’ by setting (e.g., by long-term care, by acute care), so that researchers can, at minimum, compare interventions and resulting outcomes between organizations. Elements of the definitions and typologies of special care units included environment, program elements, characteristics of residents, and training of staff [6,9,10]
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