Nursing Home Leaders Research Articles

The Fault in Our Stars: Does the Five-Star System Fall Short?

The Fault in Our Stars: Does the Five-Star System Fall Short?

Nursing Home Administrator Quality Improvement Self-Efficacy Scale.

Nursing home (NH) quality improvement (QI) is challenging. The critical role of NH leaders in successful QI is well established; however, current options for assessing the QI capabilities of leaders such as the licensed NH administrator are limited. This article presents the development and preliminary validation of an instrument to measure NH administrator self-efficacy in QI. We used a mixed-methods cross-sectional design to develop and test the measure. For item generation, 39 NH leaders participated in qualitative interviews. Item reduction and content validity were established with a sample of eight subject matter experts. A random sample of 211 administrators from NHs with the lowest and highest Centers for Medicare and Medicaid Services Five-Star Quality ratings completed the measure. We conducted exploratory and confirmatory factor analyses and tested the measure for internal reliability and convergent, discriminant, and known group validity. The final measure included five subscales and 32 items. Confirmatory factor analysis reaffirmed the factorial structure with good fit indices. The new measure's subscales correlated with valid measures of self-efficacy and locus of control, supporting the measure's convergent and discriminant validity. Significant differences in most of the subscales were found between the objective (Centers for Medicare and Medicaid Services Five-Star Quality rating) and subjective (Self-Rated Facility QI Index) quality outcomes, supporting the measure's known group validity. The instrument has usefulness to both NH organizations and individual NH administrators as a diagnostic tool to identify administrators with higher/lower chances of successfully implementing QI. Organizations and individuals can use this diagnostic to identify the administrator's professional development needs for QI, in general, and specific to the instrument's five subscales, informing directions for in-house training, mentoring, and outside professional development. Attending to NH administrators' QI professional development needs prior to implementing QI holds promise to enhance the chances for successful implementation of QI, which is urgently needed in many NHs.

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

BackgroundWhile 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.MethodsThis 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.ResultsOverall, 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).ConclusionsThe 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.

A national report of nursing home information technology: year 1 results.

To provide a report on year 1 results of a national study investigating nursing home information technology (IT) adoption, called IT sophistication. A reliable and valid survey was used to measure IT sophistication. The target goal was 10% from each state in the United States, 1570 nursing homes. A random sample of homes from each state was recruited from Nursing Home Compare. The team reached 2627 nursing home administrators, among whom 1799 administrators agreed to participate and were sent a survey. A total of 815 surveys were completed (45.3% response rate), which was below the goal. Facilities in the participating sample have similar demographic characteristics (ownership, total population in a location, and bed size) to the remaining homes not participating. There are greater IT capabilities in resident care and administrative activities, less in clinical support. The extent of use of these capabilities appears to be highest in administrative activities and lowest in clinical support. IT in resident care appears to be the most integrated with internal and external stakeholders. IT capabilities appear to be greater than IT extent of use in all health domains, with the greatest difference in resident care. National evaluations of nursing home IT are rare. Measuring trends in IT adoption in a nationally representative sample provides meaningful analytics that could be more useful for policy makers and nursing home leaders in the future. Discovering national baseline assessments is a first step toward recognizing nursing home trends in IT adoption.

Design Characteristics of Sensory Gardens in Norwegian Nursing Homes: A Cross-Sectional E-Mail Survey

ABSTRACTSensory gardens are increasingly popular in Norwegian nursing homes. This study examined the design characteristics of Norwegian sensory gardens using a cross-sectional web survey design addressing nursing home leaders (n = 121). The findings revealed that Norwegian sensory gardens were generally compliant with recommended design guidelines involving sensory experiences, stable walkways, landmarks, accessibility, visibility from indoors, seating features, and prosthetic supports. There is, however, a potential for further improvements concerning walkways with rails, access to alarm systems, clear signposts to toilets from the outdoors, lighting in the evenings, greenhouses, increased awareness of edible and nontoxic plants, and maintenance of the gardens.

Effects of Excessive Antibiotic Use in Nursing Homes.

Effects of Excessive Antibiotic Use in Nursing Homes.

Pay-for-performance policy and data-driven decision making within nursing homes: a qualitative study

IntroductionHealth systems globally and within the USA have introduced nursing home pay-for-performance (P4P) programmes in response to the need for improved nursing home quality. Central to the challenge of administering...

Clinical Use of Sensory Gardens and Outdoor Environments in Norwegian Nursing Homes: A Cross-Sectional E-mail Survey

Gardens and outdoor environments offer multiple therapeutic possibilities for the residents in nursing homes. Web-based questionnaires were sent to 488 nursing home leaders and 121 leaders responded. The clinical impressions of the leaders and staff regarding the benefits of sensory gardens (SGs) to the residents were consistent with previous research. SGs facilitated taking residents outdoors, offered convenient topics for communication and facilitated social privacy for relatives. For improved clinical use of SGs and outdoor environments, systematic assessment of residents’ interests, performance and experiences when outdoors, implementation of seasonal clinical programmes and educational programmes for leaders and staff are recommended.

Developing Palliative Care Practice Guidelines and Standards for Nursing Home–Based Palliative Care Teams: A Delphi Study

ContextLack of nursing home (NH)-specific palliative care practice guidelines has been identified as a barrier to improving palliative and end-of-life (EOL) quality of care. ObjectivesThe objectives of this study were to (1) assess which of the guidelines developed by the National Consensus Project, and the corresponding preferred care practices endorsed by the National Quality Forum, are important and feasible to implement in NHs; and (2) identify the operational standards for palliative care teams in NHs. MethodsTwo-round mail Delphi study. Based on the existing literature, a set of 7 domains with associated 22 palliative practice guidelines was drafted. We invited 48 NH leaders, including clinicians, to review the importance (10-point Likert scale) and the feasibility (5-point Likert scale) of these guidelines. Participants were also asked about palliative care team composition rounding frequency. ResultsThe response rate to both rounds was 85%. With regard to importance, the mean rating for all guidelines was 8 or higher (ie, highly important), but there was variability in agreement with regard to 5 of the guidelines. The same 5 guidelines were also considered more difficult to implement (eg, costly, unrealistic). Overall, 17 palliative care guidelines were identified for use by NH palliative care teams. Five disciplines (social work, certified nurse assistant, nurse, physician, and nurse practitioner or physician assistant) were identified as comprising a core team and 3 were proposed as extended or ad hoc members. ConclusionThe palliative care guidelines and team standards identified in this study may be helpful in providing practical direction to NH administrators and staff looking to improve palliative care practice for their residents.

Nursing Home Leadership Tenure and Resident Care Outcomes

Because of the relatively short tenure of nursing home leaders in their facilities, questions have been raised about the relationship between the length of tenure and the quality of care. The objective of this data analysis was to determine whether the tenure of nursing home administrators (NHAs) and directors of nursing (DONs) in their current facility or any facility was associated with quality as measured by survey deficiencies. This cross-sectional secondary data analysis linked tenure data from the National Nursing Home Survey and quality (deficiency) data from the Online Survey , Certification , and Reporting system to explore this relationship. Following descriptive analysis of tenure, odds ratios and confidence intervals were calculated in the presence of covariates, using Generalized Estimating Equations with a logit link. Many NHAs and DONs had relatively short tenures (less than 1 year) at their current facility (NHA 23%; DON 42%), although most had experience at other facilities. When compared to peers with long tenure, short tenure of NHAs was associated with twice the odds of having a deficiency. Short tenure of DONs was associated with four times the odds the facility had severe deficiencies as long tenure. Additional covariates, including additional experience, did not influence the results. Increasing leadership tenure in nursing facilities should be a component of quality nursing home improvement.

The ‘Unbefriended’ Challenge PA/LTC

The ‘Unbefriended’ Challenge PA/LTC

Perceptions of staff quality improvement training needs among Veterans Affairs nursing home leadership

This study seeks to describe clinical leadership’s perceptions of staff understanding of the minimum data set (MDS) quality indicators (QIs) and ways to improve staff understanding of this system, as well as specific perceived training needs among Department of Veterans Affairs (VA) nursing home care unit (NHCU) clinical leadership. This cross-sectional online survey using structured (quantitative) and open-ended (qualitative) items took place in 97 VA NHCUs nationwide. A total of 289 leadership staff including directors of nursing, medical directors, MDS coordinators participated. Qualitative analysis yielded several themes regarding why staff do/do not understand MDS QIs, and strategies to improve staff understanding included involvement, staffing/staff roles, education/training, mechanics, big picture. Regarding how to improve understanding, respondents recommended education/training, involvement, reinforcement and others. Of specific training strategies/needs, the most frequently identified were using the MDS as a clinical assessment tool. Quantitative analyses were not significant. These results highlight the range of causes identified by managers for frontline staff’s understanding (or lack thereof) of the QIs, and their preference for ways to improve staff understanding of what the MDS means. Understanding and applying these strategies may help improve staff’s use of the MDS QIs in VA and non-VA skilled nursing facilities.

Perceptions of staff quality improvement training needs among Veterans Affairs nursing home leadership

Assuring the quality of care in any healthcare provider is a central concern and finding a robust way of measuring it remains an important challenge. On one hand, quality indicators are frequently used by commissioners of care for performance management and reimbursement and also increasingly as an aid to consumer choice. On the other hand, good measurement helps staff to achieve a virtuous circle of constant improvement. Most high income countries use some sort of composite quality indicators to assure what can be a large and complex system; however, the evidence suggests that indicators are only useful if staff are engaged and committed to collecting data reliably. This paper explores the perceptions held by senior clinical leaders about the attitudes to quality assurance of frontline staff and in particular their attitudes to a standardised assessment system used widely in the USA and internationally. The Resident Assessment Instrument is used to develop care plans and a minimum data set drawn from the assessment is used to monitor quality. Surveying 97 skilled nursing facilities in the USA, the authors found that the leaders believed their staff did not fully understand how the minimum data set is used to create the quality indicators. The clinical leaders’ own perceptions are as revealing as their interpretation of the attitudes of frontline staff. The leaders themselves appear to have placed relatively little emphasis on technical aspects of improvement including trend tools and root cause analysis. They ranked training staff in specific quality improvement techniques such as statistical process control charts as the least important improvement intervention, preferring instead more training of staff to use the indicators as a clinical assessment tool. Knowing that a change is an improvement can be difficult and traditional research statistics are inappropriate due to the lack of power in individual units or organisations. Improvement Science is a relatively new discipline that explores measuring for improvement rather than for judgement and where it is embedded in practice (such as Jonkoping Council Healthcare in Sweden, Intermountain Healthcare in Utah, USA and Salford Royal NHS

Use Of Telemedicine Can Reduce Hospitalizations Of Nursing Home Residents And Generate Savings For Medicare

Hospitalizations of nursing home residents are frequent and result in complications, morbidity, and Medicare expenditures of more than a billion dollars annually. The lack of a physician presence at many nursing homes during off hours might contribute to inappropriate hospitalizations. Findings from our controlled study of eleven nursing homes provide the first indications that switching from on-call to telemedicine physician coverage during off hours could reduce hospitalizations and therefore generate cost savings to Medicare in excess of the facility's investment in the service. But those savings were evident only at the study nursing homes that used the telemedicine service to a greater extent, compared to the other study facilities. Telemedicine service providers and nursing home leaders might need to take additional steps to encourage buy-in to the use of telemedicine at facilities with such services. At the same time, closer alignment of the stakeholders that bear the costs of telemedicine and those that might realize savings because of its use could offer further incentives for the adoption of telemedicine.

Identifying medication order discrepancies during medication reconciliation: perceptions of nursing home leaders and staff

The purpose of this qualitative study was to explore nursing home leader and staff nurse perceptions about the process of medication reconciliation, with a specific focus on identifying medication order discrepancies. Medication order discrepancies and harmful discrepancy-related adverse drug events can occur when residents make the transition to nursing homes, yet little is known about how discrepancies are identified in this setting. Interviews of 18 leaders and focus groups of 13 registered nurses and 28 licensed practical nurses from eight mid-western United States nursing homes were conducted. Three themes emerged from the data: (1) nurses believe nursing home physicians rely on them to know, (2) active vs. passive information-seeking, and (3) nurses making sense of medication orders to identify discrepancies. This study provides evidence about the role of nursing home nurses in medication reconciliation and how nurses engage in cognitive processes, such as 'sensemaking', when identifying discrepancies. Nursing leaders and managers must acknowledge that medication reconciliation is a complex cognitive process that requires the right nurse be assigned to the role, taking into account education and experience. Additionally, systems to support collaboration between physicians, nurses and pharmacists should be in place to ensure that potentially harmful discrepancies are identified and resolved.

Real teams and their effect on the quality of care in nursing homes.

BackgroundUse of teams has shown to be an important factor for organizational performance. However, research has shown that a team has to meet certain criteria and operate in a certain way to realize the potential benefits of team organizing. There are few studies that have examined how teams operate in the nursing home sector and their effect on quality of care. This study investigates the relationship between teams that meet an academic definition of the team concept and quality of care in nursing homes.MethodsA cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data. Five sources of data were utilized to test our research question: (1) self-report questionnaires to 444 employees, (2) interviews with 40 ward managers, (3) self-report questionnaires to 40 ward managers, (4) telephone interviews with 378 relatives, and (5) 900 hours of field observations. Use of teams in nursing home wards was assessed by field observations and by interviews with ward mangers. Quality of care was assessed by data from surveys and interviews with relatives and staff and through field observations. All data were aggregated to the ward level and two-level analyses were used to assess the relationships.ResultsThe multi-level analyses showed that teams – as operationalized in the present study – were significantly positively related to two out of the three quality of care indices when controlled for ward size, days of sick leave and care level. One significant interaction effect was found between teams and days of sick leave, implying that the effect of teams decreased with higher numbers of days of sick leave.ConclusionsThe results suggest that teams are related to higher levels of quality of care in nursing homes. However, the study shows that there is a substantial difference between real, functional teams that meet an academic definition of the concept and quasi teams, the latter having a significantly lower effect on quality of care. Hence, nursing home leaders, directors and ward leaders should be aware of the substantial differences betweens dysfunctional – or quasi – teams and real teams, and encourage the development of real functional teams to take advantage of the potential benefits of team organizing.

Antipsychotic use drops with CMS dementia effort

The agency’s National Partnership to Improve Dementia Care has had a goal of reducing antipsychotic drug usage by 15% by the end of 2013, CMS said in an August 27 news release. Approximately 30,000 fewer nursing home residents are on these medications now than would have been. “I think the reductions in antipsychotic use observed to date are very encouraging,” Ryan Carnahan, PharmD, MS, BCPP, Clinical Associate Professor at the University of Iowa College of Public Health, told Pharmacy Today. “This is refl ective of a widespread, coordinated effort by stakeholders and providers to implement education and training to help change the way dementia care is delivered.” CMS launched the National Partnership to Improve Dementia Care on March 29, 2012. “These reductions took place in less than a year,” noted Carnahan.

Knowledge of and perceived need for evidence-based education about antipsychotic medications among nursing home leadership and staff.

Antipsychotic use is common in US nursing homes, despite evidence of increased risk of morbidity and mortality, and limited efficacy in older adults with dementia. Knowledge, attitudes, and beliefs regarding antipsychotic use among nursing home staff are unclear. The study aim was to describe nursing home leadership and direct care staff members' knowledge of antipsychotic risks, beliefs and attitudes about the effectiveness of antipsychotics and nonpharmacologic management of dementia-related behaviors, and perceived need for evidence-based training about antipsychotic medication safety. Survey of leadership and direct care staff of nursing homes in Connecticut was conducted in June 2011. Questionnaire domains included knowledge of antipsychotic risks, attitudes about caring for residents with dementia, satisfaction with current behavior management training, beliefs about antipsychotic effectiveness, and need for staff training about antipsychotics and behavior management. A total of 138 nursing home leaders and 779 direct care staff provided useable questionnaires. Only 24% of nursing home leaders identified at least 1 severe adverse effect of antipsychotics; 13% of LPNs and 12% of RNs listed at least 1 severe adverse effect. Fifty-six percent of direct care staff believed that medications worked well to manage resident behavior. Leaders were satisfied with the training that staff received to manage residents with challenging behaviors (62%). Fifty-five percent of direct care staff felt that they had enough training on how to handle difficult residents; only 37% felt they could do so without using medications. Findings suggest that a comprehensive multifaceted intervention designed for nursing homes should aim to improve knowledge of antipsychotic medication risks, change beliefs about appropriateness and effectiveness of antipsychotics for behavior management, and impart strategies and approaches for nonpharmacologic behavior management.

Concrete Steps Toward Academic Medicine in Long Term Care

Over the past 5 years, many articles have been published about the role of nursing home (NH) physician specialists in the quality of medical care in long term care settings.1e12 Recently, Katz and Pfeil7 argued in the Journal that there is a necessity to increase the credibility of NH physicians. One of the initiatives of the board of directors of the American Medical Directors Association (AMDA) was to develop a core set of competencies for physicians working in NHs. Katz and Pfeil7 state that there is also a need for NH leadership and that physicians who are embedded in the organizational culture of the homes are more likely to find success in leadership and therefore can have great impact on quality of care. Finally, Katz and Pfeil7 call for more research to demonstrate the link between physician competency and quality of care. That research can improve quality of care is also argued by Rolland and de Souto Barreto.13 They state that research can improve ongoing training of NH staff, encourage new strategies of care, including medication and nonpharmacological interventions, enhance daily practice, and can help to change negative cultural and societal representations of NHs and their workers.13 However, improving research in NHs poses many challenges for academics, as there is neither a research culture nor an adequate infrastructure to perform highquality research. Although some of the articles have pointed at the Dutch situation, most of the authors insufficiently recognize the achievements and the developments of the Dutch long term care sector and that the Netherlands already has provided some answers to the challenges raised before. We point at 2 concrete initiatives: (1) the establishment of a NH physician specialty with a 3-year training program, and (2) the establishment of academic networks of NHs providing an infrastructure for teaching, research, and best practices.

Applying the Advancing Excellence in America's Nursing Homes Circle of Success to improving and sustaining quality

Looking forward to the Quality Assurance Performance Improvement (QAPI) program to be implemented and required in 2014, and as nursing home staff provide care for residents with increasingly complex health issues, knowledge of how to implement quality improvement (QI) is imperative. The nursing home administrator and director of nursing (DON) provide overall leadership, but it is the primary responsibility of the DON and other registered nurse staff to implement and manage the day to day QI process. This article describes potential roles of nursing leaders and key components of a QI project using a pressure ulcer case study exemplar to illustrate a quality improvement process. The authors suggest specific methods that RN leaders can employ using the Advancing Excellence Campaign Circle of Success as an organizing framework along with evidence-based resources. Nursing home leaders could use this article as a guideline for implementing any clinical quality improvement process.