Nursing Staff Hours Research Articles

Organizational characteristics of highly specialized units for people with dementia and severe challenging behavior

BackgroundPeople with dementia and severe challenging behavior in the Netherlands can be temporarily admitted to highly specialized units when their behavior is not manageable in regular dementia special care units (DSCUs). With scarce evidence available for the treatment of these patients, treatment in these units is in a pioneering phase. To gain more insight into these units, this study investigated organizational characteristics, i.e. admission and discharge characteristics, staffing, the physical environment, and the management of severe challenging behavior.MethodsThree data collection methods were used: 1) a digital questionnaire to be completed by the unit manager, 2) an interview with the physician responsible for medical care and often another practitioner, and 3) an observation of the physical environment for which the OAZIS-dementia questionnaire was used. Descriptive analysis was used for quantitative data and thematic analysis for qualitative data, after which data was interpreted together. Thirteen units participated, with their sizes ranging from 10 to 28 places.ResultsPatients were mainly admitted from regular DSCUs, home or mental health care, and discharged to regular DSCUs. A multidisciplinary team comprising at least an elderly care physician or geriatrician, psychologist, and nursing staff member and other therapists as needed provided the treatment. Nursing staff hours per patient considerably differed among units. Nursing staff played a central role in the treatment. Competences such as reflectiveness on one’s own behavior, and being able to cope with stressful situations were described as relevant for nursing staff. Investing in a stable nursing staff team was described as important. The units varied in whether their work-up was more intuitive or methodological. In the diagnostic phase, observation together with an extensive analysis of the patient’s biography was essential. The units used a broad variety of interventions, and all paid attention to sensory stimuli. In the observation of the physical environment, the safety scored well and domesticity relatively low.ConclusionHighly specialized units show strong heterogeneity in organizational characteristics and management, which can be understood in the light of the pioneering phase. Despite this, similarities were found in nursing staff roles, frequent multidisciplinary evaluation, and attention to sensory stimuli.

Nursing Homes Increasingly Rely On Staffing Agencies For Direct Care Nursing.

When nursing homes experience a shortage in directly employed nursing staff, they may rely on temporary workers from staffing agencies to fill this gap. This article examines trends in the use of staffing agencies among nursing homes during the prepandemic and COVID-19 pandemic era (2018-22). In 2018, 23percent of nursing homes used agency nursing staff, accounting for about 3percent of all direct care nursing hours worked. When used, agency staff were commonly present for ninety or fewer days in a year. By 2022, almost half of all nursing homes used agency staff, accounting for 11percent of all direct care nursing staff hours. Agency staff were increasingly used to address chronic staffing shortages, with 13.8percent of nursing homes having agency staff present every day. Agency staff were 50-60percent more expensive per hour than directly employed nursing staff, and nursing homes that used agency staff often had lower five-star ratings. Policy makers need to consider postpandemic changes to the nursing home workforce as part of nursing home reform, as increased reliance on agency staff may reduce the financial resources available to increase nursing staff levels and improve the quality of care.

NURSING HOME WORKFORCE CHALLENGES: INCREASED NURSING STAFF LABOR COSTS AND USE OF AGENCY STAFF FROM 2017 TO 2021

Abstract Nursing homes face rapidly increasing wages and change their input mix as they face workforce shortfalls. For 15,959 freestanding NHs from 2017-2021, the proportion of hours worked by agency staff and the median wage cost per hour of agency and directly employed nursing staff were calculated from Medicare cost reports and Payroll-Based Journal data. The median hourly wage cost of directly employed staff (wage and fringe) increased 18.1% for RNs (to $41.99 in 2021), 19.8% for LPNs ($32.29), and 27.5% for CNAs ($19.62). The median hourly wage cost of agency staff (amount paid to staffing agency) increased at a faster rate and was substantially higher: 22.8% for RNs ($64.19); 28.3% for LPNs ($52.42), and 34.9% for CNAs ($33.73). The use of agency staff increased, starting from approximately 2% of all nursing staff hours for each of the nursing staff types in Q1 2017 to 5.6% hours for RNs, 9.4% hours for LPNs, and 8.8% hours for CNAs in Q4 2021. These observations have implications for quality and access to nursing home care. High use of agency staff may affect quality of nursing home care, and substantial wage differences between agency and directly-employed staff may affect worker satisfaction and attachment of directly employed workers. Hourly wage costs for all nursing staff have increased more rapidly than nursing home revenues, which only increased 16.6% over the study period; this suggests that, without payment rate increases, nursing homes may reduce labor inputs to contain costs, or may go out of business.

The Impact of Nursing Staffs' Working Conditions on the Quality of Care Received by Older Adults in Long-Term Residential Care Facilities: A Systematic Review of Interventional and Observational Studies.

Background: Little documentation exists on relationships between long-term residential care facilities (LTRCFs), staff working conditions and residents’ quality of care (QoC). Supporting evidence is weak because most studies examining this employ cross-sectional designs. Methods: Systematic searches of twelve bibliographic databases sought experimental and longitudinal studies, published up to May 2021, focusing on LTRCF nursing staff’s working conditions and the QoC they provided to older adults. Results: Of the 3577 articles identified, 159 were read entirely, and 11 were retained for inclusion. Higher nursing staff hours worked per resident per day (HPRD) were associated with significant reductions in pressure sores and urinary tract infections. Overall staff qualification levels and numbers of RNs had significant positive influences on QoC. Conclusions: To the best of our knowledge, this systematic review is the first to combine cohort studies with a quasi-experimental study to explore associations between LTRCF nursing staff’s working conditions and older adult residents’ QoC. Human factors (including HPRD, staff turnover, skill mix, staff ratios) and the specific working contribution of RNs had overwhelmingly significant influences on QoC. It seems essential that LTRCF supervisory and decision-making bodies should promote optimal working conditions for nursing staff because these have such a direct impact on residents’ QoC.

Changing landscape of nursing homes serving residents with dementia and mental illnesses.

Nursing homes (NHs) are serving an increasing proportion of residents with cognitive issues (e.g., dementia) and mental health conditions. This study aims to: (1) implement unsupervised machine learning to cluster NHs based on residents' dementia and mental health conditions; (2) examine NH staffing related to the clusters; and (3) investigate the association of staffing and NH quality (measured by the number of deficiencies and deficiency scores) in each cluster. 2009-2017 Certification and Survey Provider Enhanced Reporting (CASPER) were merged with LTCFocUS.org data on NHs in the United States. Unsupervised machine learning algorithm (K-means) clustered NHs based on percent residents with dementia, depression, and serious mental illness (SMI, e.g., schizophrenia, anxiety). Panel fixed-effects regressions on deficiency outcomes with staffing-cluster interactions were conducted to examine the effects of staffing on deficiency outcomes in each cluster. We identified 110,463 NH-year observations from 14,671 unique NHs using CASPER data. Three clusters were identified: low dementia and mental illnesses (Postacute Cluster); high dementia and depression, but low SMI (Long-stay Cluster); and high dementia and mental illnesses (Cognitive-mental Cluster). From 2009 to 2017, the number of Postacute Cluster NHs increased from 3074 to 5719, while the number of Long-stay Cluster NHs decreased from 6745 to 3058. NHs in Long-stay/Cognitive-mental Clusters reported slightly lower nursing staff hours in 2017. Regressions suggested the effect of increasing staffing on reducing deficiencies is statistically similar across NH clusters. For example, 1 hour increase in registered nurse hours per resident day was associated with -0.67 (standard error [SE] = 0.11), -0.88 (SE=0.12), and -0.97 (SE=0.15) deficiencies in Postacute Cluster, Long-stay Cluster, and Cognitive-mental Cluster, respectively. Unsupervised machine learning detected a changing landscape of NH serving residents with dementia and mental illnesses, which requires assuring staffing levels and trainings are suited to residents' needs.

Association between nursing home staff turnover and infection control citations.

To describe the association between nursing home staff turnover and the presence and scope of infection control citations. Secondary data for all US nursing homes between March 31, 2017, through December 31, 2019 were obtained from Payroll-Based Journal (PBJ), Nursing Home Compare, and Long-Term Care: Facts on Care in the US (LTC Focus). We estimated the association between nurse turnover and the probability of an infection control citation and the scope of the citation while controlling for nursing home fixed effects. Our turnover measure is the percent of the facility's nursing staff hours that were provided by new staff (less than 60 days of experience in the last 180 days) during the 2 weeks prior to the health inspection. We calculated turnover for all staff together and separately for registered nurses, licensed practical nurses (LPNs), and certified nursing assistants. We linked nursing homes standard inspection surveys to 650 million shifts from the PBJ data. We excluded any nursing home with incomplete or missing staffing data. Our final analytic sample included 12,550 nursing homes with 30,536 surveys. Staff turnover was associated with an increased likelihood of an infection control citation (average marginal effect [AME]=0.12 percentage points [pp]; 95% confidence interval [CI]: 0.05, 0.18). LPN (AME=0.06 pp; 95% CI: 0.01, 0.11) turnover was conditionally associated with an infection control citation. Conditional on having at least an isolated citation for infection control, staff turnover was positively associated with receiving a citation coded as a "pattern" (AME=0.21 pp; 95% CI: 0.10, 0.32). Conditional of having at least a pattern citation, staff turnover was positively associated with receiving a widespread citation (AME=0.21 pp; 95% CI: 0.10, 0.32). Turnover was positively associated with the probability of an infection control citation. Staff turnover should be considered an important factor related to the spread of infections within nursing homes.

Association between Nursing Home Staff Turnover and Infection Control Citations

Objective: To describe the association between nursing home staff turnover and the presence and scope of infection control citations. Data Sources: Secondary data for all U.S. nursing homes between March 31, 2017 through December 31, 2019 from Payroll-Based Journal (PBJ), Nursing Home Compare, and Long-Term Care Facts on Care in the U.S.Study Design: We estimated the association between nurse turnover and the probability of an infection control citation and the scope of the citation, while controlling for nursing home fixed effects. Our turnover measure is the percent of the facility’s nursing staff hours that were provided by new staff (less than 60 days of experience in last 180 days) during the two weeks prior to the health inspection. We calculated turnover for all staff together and separately for registered nurses, licensed practical nurses (LPNs), and certified nursing assistants. Data collection/Extraction methods: We linked nursing homes standard inspection surveys to 650 million shifts from the PBJ data. We excluded any nursing home with incomplete or missing staffing data. Our final analytic sample included 12,550 nursing homes with 30,536 surveys.Principal Findings: Staff turnover was associated with an increased likelihood of an infection control citation (average marginal effect [AME]=0.12 percentage points (pp); 95% Confidence Interval (CI): 0.05,0.18). LPN (AME=0.06 pp; 95%CI: 0.01,0.11) turnover was conditionally associated with an infection control citation. Conditional on having at least an isolated citation for infection control, staff turnover was positively associated with receiving a citation coded as a “pattern” (AME=0.21 pp; 95%CI: 0.10,0.32). Conditional of having at least a pattern citation, staff turnover was positively associated with receiving a widespread citation (AME=0.21 pp; 95%CI: 0.10,0.32). Conclusions: Turnover was positively associated with the probability of an infection control citation. Staff turnover should be considered an important factor related to the spread of infections within nursing homes.

Age Matters: Building Blocks Needed to Inform Nurse Staffing Hours Requirements in Residential Care for Older Adults

This study addresses the need for more complete information about the impact of nurse staffing hours (NSH) on nursing home quality of care. We used national data to examine the relationship between three types (Registered Nurse, Licensed Practical Nurse, and Nurse Aide) of hours, and long-stay quality of care measures over time, taking into account the possible confounding influence of regional differences. Data analyzed were from U.S. Nursing Home Compare datasets which reflect quarterly reports, July 1, 2018 - June 30, 2019 (14,768 facilities). The hours for each staff type in each facility were compared with the facility’s four-quarter quality average scores for each of the 12 measures. Results showed only one strong and statistically significant relationship (Beta= .548; p< .001) between Nurse Aide hours and the quality measure used in data sets to exemplify facilities that serve “lower-risk” residents. Analyzes using multiple R (.517) indicate that the linear combination of the three NSH types strongly and significantly (p< .001) predicted the four-quarter average scores and explained 27% of the variance in the scores. Holding the other two NSH types constant, the scores for that measure increased by 63 for each additional increase in the Nurse Aide nurse staffing hours per resident per day. There was no multicollinearity among the three types of staffing hours. This research adds information to the foundation needed for future research about process indicators to assess their efficacy as measures of actual quality of care, and will be submitted as a Technical Note to journals.

Nurse Staffing Hours At Nursing Homes With High Concentrations Of Minority Residents, 2001-11.

Recent increases in state Medicaid payments to nursing homes have the potential to reduce disparities in nurse staffing between facilities with high and low concentrations of racial/ethnic minority residents. Analyses of nursing home and state policy survey data for the period 2001-11 suggest that registered nurse and licensed practical nurse staffing levels increased slightly during this period, regardless of racial/ethnic minority resident concentration. Adjusted disparities in registered nurse hours per resident day between nursing homes with high and low concentrations of minority residents persisted, although they were reduced. Certified nursing assistant hours per patient day increased in nursing homes with low concentrations of minorities but decreased in homes with high concentrations, creating a new disparity. Overall, increases in state Medicaid payment rates to nursing homes were associated with improvements in staffing and reduced staffing disparities across facilities, but the adoption of case-mix payments had the opposite effect. Further reforms in health care delivery and payment are needed to address persistent disparities in care between nursing homes serving higher proportions of minority residents and those serving lower proportions, and to prevent unintended exacerbations of such disparities.

Nurse Staffing Levels and Patient-Reported Missed Nursing Care.

A total of 729 inpatients were surveyed using the MISSCARE Survey-Patient. Missed timeliness, patient reports of the time it took for them to receive care from nursing staff, was negatively associated with total nursing staff hours of care per patient-day (r = -0.09, P = .015), registered nurse (RN) hours per patient-day (r = -0.14, P = .0002), and RN skill mix (r = -0.13, P = .0004). RN skill mix was also a predictor of missed timeliness (P = .01).

Predictors of Antipsychotic Medication Use in Nursing Home Residents

The prevalence of antipsychotic medication use in nursing home patients continues to be substantial and may be increasing despite restrictions on their use (Briesacher et al., 2005). These medications are indicated for psychotic symptoms such as delusions and hallucinations, but are not well-supported for use in controlling problematic behaviors associated with cognitive impairment. A 2004 study found that although diagnoses related to psychotic symptoms were strongly predictive of antipsychotic use, there were other personal and clinical predictors, such as a diagnosis of dementia and behavioral symptoms, that might contribute to inappropriate antipsychotic use (Kamble, Chen, Sherer, & Aparasu, 2008). To our knowledge, no studies have used validated scales measuring the severity of behavioral symptoms and cognitive impairment to examine the degree to which these factors might be associated with antipsychotic use. Two-hundred eighty nursing home patient medical records were randomly selected from nineteen nursing homes, and data were extracted from the Minimum Data Set 2.0 (MDS 2). We used logistic regression analyses to predict use of antipsychotics in the previous seven days. We controlled for age because prior research suggests that younger patients are more likely to receive antipsychotics than older patients. The severity of cognitive impairment was measured with the validated Cognitive Performance Scale (CPS) (Morris et al., 1994), and the severity of behavioral symptoms was measured using the validated Aggressive Behavior Scale (ABS) (Perlman & Hirdes, 2008). We also included a facility-level variable, the number of licensed nursing staff hours per resident per day as recorded by the Centers for Medicare and Medicaid Services' website. We found severity of cognitive impairment (OR = 1.35, 95% CI, 1.05-1.74), severity of behavioral symptoms (OR = 1.38, 95% CI, 1.01-1.88), and age (OR = .97, 95% CI, .95-.99) to be predictive of antipsychotic use. We found the number of staffing hours (OR = .98, 95% CI, .97-1.00) to be nearly significant in the prediction of antipsychotic use. Descriptive statistics, however, indicate that two of nineteen facilities contributed forty percent of people on an antipsychotic. The results support the notion that cognition and behaviors are important drivers of antipsychotic use and that facility characteristics and staffing should be further explored as a possible issue related to this outcome.

Estimating the nursing staff required in a new hospital

Opening a new hospital poses a complex and consequential set of challenges. One of these challenges is to estimate the nursing staff. The aim of this article is to report the entire process adopted to estimate the required nursing staff for a new Hospital in Brazil. The nursing staff was projected according to the Brazilian Federal Nursing Council (Cofen). We applied an equation to estimate nursing staff and compared the results with two other existing hospitals. A significant difference (p<0.05) was observed when comparing the Nurse-License Practice Nurse ratio recommended by Cofen between the new Hospital and other hospitals. This statistical difference is mostly due to reduced nurse staff in intensive care units. Almost one year after the hospital opened its doors, it is necessary to review nursing staff hours with the real information to reinforce the expenditure on these personnel and to evaluate the decisions made so far.

Can the Northwick Park Care Needs Assessment be used to estimate nursing staff requirements in an inpatient rehabilitation setting?

Aim : To determine whether the Northwick Park Care Needs Assessment (NPCNA) could be used to estimate nursing staff requirements in an inpatient rehabilitation setting. Design : Retrospective analysis of NPCNA data in comparison with nursing staff provision over a six-month period from 1 April 2003 to 30 September 2003. Setting : A specialist neurorehabilitation unit. Methods : Daily care requirements for the ward were calculated at two-week intervals by summing the NPCNA care-hour estimates for all inpatients. Nursing staff hours provided were identified from the unit's duty rota and agency records for each corresponding period. Results : In total, 271 care-hour recordings were extracted from 59 patients. There was a poor relationship between the calculated total ward care-hour requirements and nursing staff hours provided (Pearson's r = 0.31, P = 0.29); but staff hours provided fell significantly short of estimated daily care requirements (mean shortfall 6.2 hours/day, SD 8.6 (95% confidence interval (CI) 0.73, 11.1), P = 0.03)). The shortfall was most obvious during peak care periods in the morning and at bedtime, which resonates with experience reported by nursing staff that they are overstretched at these times. A marked discrepancy between qualified nursing staff hours provided and NPCNA-estimated `special nursing' care requirements highlights a failure to address important facets of the rehabilitation nursing role. Conclusions : The NPCNA, which was designed to assess only direct care needs in a community setting, requires the further development of a new algorithm before it could be used to estimate nursing staff requirements in a rehabilitation ward setting.

Iowa Nursing Home Characteristics Associated With Reported Abuse

To evaluate the association of nursing home abuse reported by employees in Iowa licensed nursing homes with nursing home characteristics, inspection results, nursing staff hours, and census demographics. Mailed survey. Iowa's 409 Medicare-certified stand-alone nursing homes. Administrators and directors of nursing. The annual rate of abusive events was 20.7 per 1000 nursing home residents, with a rate of 18.4 reported events and 5.2 substantiated events. A higher number of residents and a higher number of certified beds were significantly associated with higher incident, report, and substantiation rates. Higher incident and report rates were associated with nursing homes in metropolitan areas. Higher substantiation rates were associated with for-profit nursing homes. Recognized abuse in nursing homes is not uncommon. Approximately 90% of events are reported to the state authorities with 29% of those being substantiated. Differences associated with nursing facility abuse rates are metropolitan area, ownership, occupancy rate, and number of residents and certified beds.

Relationship of Nursing Personnel and Nursing Home Care Quality

The purpose of this study was to examine the associations between nurse staffing hours and 6 quality indicators: physical restraints, weight loss, incontinence, late loss activities of daily living decline, stages 1 to 4 pressure ulcers, and problem behaviors toward others. Increasing registered nurse staff hours may achieve better quality indicator scores for pressure ulcers. An increase in nurse aide hours should be carefully weighed with the amount of registered nurse staff time available for supervision and direction.

Total quality management and the reduction of inpatient violence and costs in a forensic psychiatric hospital.

The study evaluated the effects of using the principles of total quality management (TQM) to reduce aggressive incidents in the dining rooms at a state forensic hospital. A ten-member, multidisciplinary team, which included a patient representative and a private-sector mentor, used the TQM FADE method (focus, analyze, develop, and execute) to address the problem. The team analyzed violent mealtime incidents, reviewed mealtime policies and procedures, and conducted a patient survey. Five recommendations were made: substitute plastic utensils for silverware, play music selected by the hospital's music therapists, allow patients at the highest privilege levels to leave the dining room after eating, open the main courtyard and gym during meals, and train food service workers in therapeutic communication. One year after implementation of the recommendations, aggressive incidents in the dining rooms were reduced by 40 percent, assaults using silverware were eliminated, and a total of 70 nursing staff hours a day were saved by eliminating silverware control procedures in the dining rooms. The milieu in the dining rooms has been improved by the addition of music and more flexible procedures. TQM techniques can be effectively applied in public-sector institutions to analyze and solve problems such as mealtime violence.