Quality Of Care For Residents Research Articles

Implementation of the Dementia Isolation Toolkit in long-term care improves awareness but does not reduce moral distress amongst healthcare providers

BackgroundHealthcare providers may experience moral distress when they are unable to take the ethically or morally appropriate action due to real or perceived constraints in delivering care, and this psychological stressor can negatively impact their mental health, leading to burnout and compassion fatigue. This study describes healthcare providers experiences of moral distress working in long-term care settings during the COVID-19 pandemic and measures self-reported levels of moral distress pre- and post-implementation of the Dementia Isolation Toolkit (DIT), a person-centred care intervention designed for use by healthcare providers to alleviate moral distress.MethodsSubjective levels of moral distress amongst providers (e.g., managerial, administrative, and front-line employees) working in three long-term care homes was measured pre- and post-implementation of the DIT using the Moral Distress in Dementia Care Survey and semi-structured interviews. Interviews explored participants’ experiences of moral distress in the workplace and the perceived impact of the intervention on moral distress.ResultsA total of 23 providers between the three long-term care homes participated. Following implementation of the DIT, subjective levels of moral distress measured by the survey did not change. When interviewed, participants reported frequent experiences of moral distress from implementing public health directives, staff shortages, and professional burnout that remained unchanged following implementation. However, in the post-implementation interviews, participants who used the DIT reported improved self-awareness of moral distress and reductions in the experience of moral distress. Participants related this to feeling that the quality of resident care was improved by integrating principals of person-centered care and information gathered from the DIT.ConclusionsThis study highlights the prevalence and exacerbation of moral distress amongst providers during the pandemic and the myriad of systemic factors that contribute to experiences of moral distress in long-term care settings. We report divergent findings with no quantitative improvement in moral distress post-intervention, but evidence from interviews that the DIT may ease some sources of moral distress and improve the perceived quality of care delivered. This study demonstrates that an intervention to support person-centred isolation care in this setting had limited impact on overall moral distress during the COVID-19 pandemic.

Family Involvement among Oregon Adult Foster Home Residents, 2018–2023

ObjectivesTo track the changes that occurred in family involvement among Oregon Adult Foster Home (AFH) residents following the COVID-19 pandemic and to examine the associations between home and resident characteristics and family involvement. DesignRetrospective analysis of repeated cross-sectional data. Setting and ParticipantsA total of 2027 responses from AFH providers that replied to a mailed questionnaire from a sample of eligible licensed Oregon AFH selected to participate annually between 2018 and 2023 (6 waves). MethodsAFH providers filled out a questionnaire containing questions about family involvement (residents who received 6 types of support from family members or friends, such as help with personal care or social visit) and resident characteristics (activities of daily living needs, payer mix, age, gender, dementia status). Additional contextual data (size, rural/urban) were obtained from state agencies. Associations among family involvement and home and resident characteristics were examined using multivariable linear regression models. ResultsBivariate analyses showed statistically significant declines in social visits and outings and help getting to medical appointments during the first 2 years (2021 and 2022) of the COVID-19 pandemic, but little change in help with personal care or taking medications or phone calls. By 2023, social visits had recovered to pre-pandemic levels but remained significantly lower for help getting to medical appointments and going on outings. Multiple regression models that included controls showed that rural AFH and those with higher Medicaid use reported significantly lower family involvement in social visits, outings, and help getting to medical appointments. Conclusions and ImplicationsThe continued decline in assistance for medical appointments and outings portends potential challenges in resident socioemotional well-being and accessing health care services in this setting. Understanding the long-term impacts of the pandemic on quality of life and quality of care for residents living in community-based care settings may require a multifaceted approach to measuring family involvement.

Quality of care as perceived by caregivers and residents in aged care homes in Sri Lanka: a qualitative study

ObjectiveQuality of care determines the physical and psychological wellbeing of aged care residents. The study aims to explore barriers and facilitators of quality of care in aged care homes (ACHs) in Sri Lanka from the perspective of older adults and caregivers.MethodsThis qualitative descriptive exploratory study was conducted in selected five ACHs in Galle District, Sri Lanka, from May 2021 to January 2022. We recruited a purposive sample of residents and caregivers and conducted ten in-depth interviews with ten caregivers and nine focus group discussions with forty-five residents. The data were analysed using the thematic analysis.ResultsThe majority of caregivers and residents were females. Caregivers and residents were aged 25-35 years and 70-80 years, respectively. Two major themes emerged: (a) barriers of quality of care and (b) facilitators of quality of care. Both residents and caregivers reported a lack of referring system facilities; a lack of financial support on the infrastructure; a lack of financial support in supplying medication and employing human resources; insufficient knowledge of gerontological care and geriatric syndromes for both caregivers and residents; and lack of interest in being a caregiver at the ACHs as barriers in providing quality care. Moreover, caregivers and older people reported donations by philanthropists; supportive leadership; and welfare benefits from the government authorities as facilitators of quality care. Additionally, caregivers reported a lack of in-service programmes for caregivers as a barrier and positive institutional values as a facilitator for providing quality care.ConclusionThe available human and physical resources are insufficient to address the demanding needs of residents in ACHs, apart from the received donations. There is a simultaneous need for healthcare policymakers' and social welfare authorities' attention to implementing necessary measures to uplift the quality of care for residents in ACHs to enhance their quality of life.

THE IMPACT OF COVID-19 ON RELATIONSHIPS BETWEEN CARE TEAMS AND FAMILY CAREGIVERS IN CONGREGATE CARE

Abstract Family/friend caregivers are essential in the quality of care and life of residents living in congregate care (nursing homes and assisted living). However, the COVID-19 pandemic and related public health measures substantially changed the way family/friend caregivers could be involved in resident care. It also changed the dynamic of the relationships between care teams and family/friend caregivers. While research has explored these impacts, much of the research has focused on the family/friend caregiver perspective. Our objective was to explore the impact of COVID-19 and related public health measures on these relationships from the perspective of care teams. Using videoconferencing, we conducted 9 focus groups and 2 semi-structured interviews (total of 37 participants) with managers/administrators of 6 congregate care settings and their teams (care aides, nurses, recreation and rehabilitation staff, educators). The themes we identified reflect (1) pressures care teams experienced from family/friend caregivers, (2) conflicts between care teams and family/friend caregivers, (3) support care teams received from family/friend caregivers, and (4) how care teams supported family/friend caregivers. The COVID-19 pandemic disrupted long-standing relationships between care teams and family/friend caregivers, negatively impacting care teams, family/friend caregivers, and residents. However, care teams also reported encouraging examples of successful collaboration and support from family/friend caregivers. Involving family-friend caregivers in decision making was particularly critical. Learning from these promising practices will be critical to improving preparedness for future public health crises, as well as quality of resident care and life in general.

ASSISTED LIVING ADMINISTRATORS’ PERSPECTIVES OF HOW COVID-19 AFFECTED DIRECT CARE STAFF

Abstract Background Coronavirus disease 2019 (COVID-19) presented many new challenges within assisted living communities (ALCs) and exacerbated preexisting challenges. With high quality of care in ALCs as the continuous goal to achieve, it is important to recognize challenges faced in these communities, especially those related to staffing and COVID-19. Objective: The objective was to investigate issues related to staffing and the effect of COVID-19 in ALCs, including staff absence, leadership, impacts on staff, and impacts on staff retention. Methods Participants were ALC administrators (N=129) from the parent study of the Strategic Approach to Facilitating Evacuation by Health Assessment of Vulnerable Elderly in Nursing Homes II (SAFEHAVEN II) funded by the National Institute on Aging. Quantitative analysis was used to determine structure and process characteristics of ALCs during COVID-19 that impacted a process outcome. Qualitative analyses were used to gain perspectives of administrators about the impact of COVID-19 within their ALCs. Results Provision of memory care services (structure characteristic), challenge with staff sent home to comply with COVID-19 precautions, challenge paying staff for time off due to COVID-19, and staff anxiety (process characteristics) were significant predictors of staff absence from work (process outcome). Three key themes interpreted from administrators’ interviews were Leadership Shown Toward Staff, Impact of COVID-19 on Staff, and Impact of COVID-19 on Staff Retention. Implications: This dissertation discusses implications for research, policy, and practice to inform continual efforts to improve aspects of staffing and the quality of resident care in ALCs.

IMPACT OF UNIFORMS IN LONG-TERM CARE FACILITIES: SYNTHESIS OF INTERNATIONAL EVIDENCE AND SURVEY OF UK STAFF VIEWS

Abstract Non-uniform-based staff dress codes are beginning to emerge in UK long-term care facilities for older people. However, there is little research evidence on the impact of staff clothing on resident, staff and visitor experiences, wellbeing or quality of life. Uniforms may be reassuring and facilitate identification of staff; a non-uniform approach may create a home-like, relaxed environment. This study aimed to synthesise existing international evidence and explore staff views about work clothing in three not-for-profit long-term care facilities in the UK. Five bibliometric databases were searched from inception. A narrative synthesis of included papers was conducted due to heterogeneity of study designs and outcome reporting. 77 (49%) of 158 staff responded to the survey. 68 staff (88%) did not currently wear a uniform at work. Views about the importance and impact of uniform were mixed: 25 (32%) believed that their role needed a uniform; 60 (78%) thought staff clothing made no difference in resident care quality but 45 (58%) agreed the environment felt more home-like when staff did not wear a uniform. 36 staff (47%) would choose to wear a uniform and 17 staff (22%) reported finding it difficult to afford clothes for work. In the context of limited research evidence, staff clothing is perceived to have little impact on care quality but considerable impact on long-term care facility atmosphere and staff working experiences. There is a need to research the impact of staff clothing to support evidence-based decisions about staff clothing policies in long-term care settings.

A Critical Dialogue on Residential Care for Children and Youth: What We Really Know and Questions of Quality

ABSTRACT The conventional belief that residential care is harmful to children and youth held by many organizations and individuals has been challenged in a recent book reviewing a broad range of the recent empirical literature. In a dialogue format, we discuss the historical context in which the book developed, its key points, and the implications and questions it raises about providing and supporting high quality residential care. The negative view of residential care has its roots in the inappropriate generalization of research results on infants and very young children in deprived environments to older children in more enriched environments. The research on residential care for children and youth shows that the quality of care is more important than its site. Research also highlights the features of care that are most important to high quality, including the centrality of sensitive, reciprocal positive relationships. We offer some “wicked questions” that can be used by practitioners in their reflections on the care they provide and to begin to change the international conversation about residential care.

Cross-perspectives on telemedicine in nursing homes: a survey of professionals involved in the setting-up of teleconsultations in nursing homes in Rennes area

The practice of telemedicine in nursing homes is a solution to improve the quality of care for residents. Its application also seems to be beneficial for the professionals involved, but it faces obstacles. The objective of this study is to explore the effects of the implementation of teleconsultations in nursing homes on the professional practices of the stakeholders involved. A qualitative focus group study was conducted with professionals involved in the implementation of teleconsultations. The data was analyzed using an inductive approach similar to grounded theory. The 18 participants included in the study were unanimous and consensual about the benefits of telemedicine. They observed changes in work relationships, particularly the key role of caregivers in coordinating care. However, they feared a deterioration in doctor-patient relationships. The practice of telemedicine was considered time-consuming, which could hinder its dissemination. No general practitioner participated in this study, showing they had reservations about the practice. The Covid-19 pandemic had an impact on the development of teleconsultations within the institutions involved. Telemedicine is acclaimed by the nursing homes teams and the doctors required, particularly through the effects on training and the added value it can bring to their practice. Telemedicine also allows to provide care that is otherwise not available. However, the care process needs to be simplified. In addition, there are obstacles to the involvement of general practitioners, which should be studied in order to optimize the coordination of care for the residents of the nursing homes.

Forming Nursing Home Practices That Support Quality of Care for Residents. A Qualitative Observational Study.

Residents of nursing homes are increasingly frail and dependent. At the same time, there are increased demands for quality of care and social life for individual residents. In this article, we explore how care workers contribute to quality of care and social life in shared living rooms in nursing homes. An ethnographically inspired design was applied, and a purposive sample of six units for long-term care in three nursing homes in Norway was included in the study. Data were collected by participant observation, including informal conversations with the staff and residents, and the data were analyzed using thematic analysis. The analysis identified three main themes: working within the given context, creating care practices and organizing activities. The empirical findings demonstrate that care work focuses on meeting both the residents' physical and social needs and aiming for high-quality care and social life for the residents in nursing homes. The results of this study illustrate that nursing home practices are focused on residents as a group. However, care workers take advantage of personal skills and resources to work towards person-centred care within the given context. The quality of care is recognized in terms of how care workers meet individual residents' needs. The quality of care seems highly related to the capability and skills of individual care workers.

What happens to children who don’t behave in residential care? A multi-informant mixed-methods study on discipline strategies

In Portugal in 2021, 85% of children placed in out-of-home care were in non-specialised residential care. Evidence on discipline strategies used in these childcare contexts is scarce. This study aims at analysing the discipline strategies used by caregivers in residential care based on multiple informants’ reports - children/adolescents in care, caregivers, and directors. It follows a theoretical framework that includes and relates the concepts of quality in residential care, positive discipline, and the child’s rights. A total of 422 children/adolescents, 266 caregivers and 60 directors in 60 residential care centres participated in this study. Data on discipline strategies were collected by interviewing all the participants and analysed using a mixed methodology. A content analysis allowed for the identification of 32 subcategories, organised into six categories, which were computed into three major types of discipline strategies: Positive and Induction-Based Strategies, Punitive Strategies, and Strategies that Violate the Child’s Rights. Additionally, a cluster analysis based on the reports of the three informants led to the identification of three groups of residential care centres that used different discipline strategies - Punitive Centres, Inductive Centres, and Rights-Violating Centres. Findings showed that Punitive Centres tend to be gender-mixed and Rights-Violating Centres tend to be gender-segregated. This study also revealed the frequent use of punitive discipline strategies that violate the child’s rights in residential care, requiring the need to provide qualified training to caregivers on appropriate discipline strategies.

The impact of COVID-19 on relationships between family/friend caregivers and care staff in continuing care facilities: a qualitative descriptive analysis

BackgroundThe COVID-19 pandemic and related public health measures added a new dynamic to the relationship between caregivers and care staff in congregate care settings. While both caregivers and staff play an important role in resident quality of life and care, it is common for conflict to exist between them. These issues were amplified by pandemic restrictions, impacting not only caregivers and care staff, but also residents. While research has explored the relationship between caregivers and care staff in long-term care and assisted living homes, much of the research has focused on the caregiver perspective. Our objective was to explore the impact of COVID-19-related public health measures on caregiver-staff relationships from the perspective of staff in long-term care and assisted living homes.MethodsWe conducted 9 focus groups and 2 semi-structured interviews via videoconference.ResultsWe identified four themes related to caregiver-staff relationships: (1) pressure from caregivers, (2) caregiver-staff conflict, (3) support from caregivers, and (4) staff supporting caregivers.ConclusionsThe COVID-19 pandemic disrupted long-standing relationships between caregivers and care staff, negatively impacting care staff, caregivers, and residents. However, staff also reported encouraging examples of successful collaboration and support from caregivers. Learning from these promising practices will be critical to improving preparedness for future public health crises, as well as quality of resident care and life in general.

Safer Care for Older Persons in (residential) Environments (SCOPE): a pragmatic controlled trial of a care aide-led quality improvement intervention

BackgroundThe increased complexity of residents and increased needs for care in long-term care (LTC) have not been met with increased staffing. There remains a need to improve the quality of care for residents. Care aides, providers of the bulk of direct care, are well placed to contribute to quality improvement efforts but are often excluded from so doing. This study examined the effect of a facilitation intervention enabling care aides to lead quality improvement efforts and improve the use of evidence-informed best practices. The eventual goal was to improve both the quality of care for older residents in LTC homes and the engagement and empowerment of care aides in leading quality improvement efforts.MethodsIntervention teams participated in a year-long facilitative intervention which supported care aide-led teams to test changes in care provision to residents using a combination of networking and QI education meetings, and quality advisor and senior leader support.This was a controlled trial with random selection of intervention clinical care units matched 1:1 post hoc with control units. The primary outcome, between group change in conceptual research use (CRU), was supplemented by secondary staff- and resident-level outcome measures. A power calculation based upon pilot data effect sizes resulted in a sample size of 25 intervention sites.ResultsThe final sample included 32 intervention care units matched to 32 units in the control group. In an adjusted model, there was no statistically significant difference between intervention and control units for CRU or in secondary staff outcomes. Compared to baseline, resident-adjusted pain scores were statistically significantly reduced (less pain) in the intervention group (p=0.02). The level of resident dependency significantly decreased statistically for residents whose teams addressed mobility (p<0.0001) compared to baseline.ConclusionsThe Safer Care for Older Persons in (residential) Environments (SCOPE) intervention resulted in a smaller change in its primary outcome than initially expected resulting in a study underpowered to detect a difference. These findings should inform sample size calculations of future studies of this nature if using similar outcome measures. This study highlights the problem with measures drawn from current LTC databases to capture change in this population. Importantly, findings from the trial’s concurrent process evaluation provide important insights into interpretation of main trial data, highlight the need for such evaluations of complex trials, and suggest the need to consider more broadly what constitutes “success” in complex interventions.Trial registrationClinicalTrials.gov, NCT03426072, registered August 02, 2018, first participant site April, 05, 2018.

Effectiveness of a Smart Urinary Continence Care Assessment System for Nursing Home Residents: A Quasi-Experimental, Sequential Quantitative-Qualitative Methods Trial.

The purpose of this study was to compare the effect of use of an electronic urinary continence assessment system versus usual care on construction of care plans, resource use, and continence care for nursing home (NH) residents. Convergent mixed-methods study comprising a prospective, parallel arm-controlled phase, and concurrent qualitative component. The study setting was Alberta, a province in Western Canada. Residents requiring a continence assessment or reassessment in an NH with 2 units assigned to intervention (I) and 2 units to usual care (UC). One hundred one residents (I: n = 49; UC: n = 52) participated; 89 (I: n = 43; UC: n = 46) completed the study. The mean age of the UC group was 88.5 (SD = 6.9) years, whereas the mean age of the intervention group was 85.6 (SD = 7.5) years. Quantitative data on assessment, resource use, resident quality of life, and continence care outcomes were collected at weeks 0, 2, and 8; plan adherence was assessed at week 16. Qualitative data were collected via interviews. Analysis revealed a significant change in the proportion of residents achieving a reduction in 24-hour pad absorbency (50.6% vs 39.1%, P = .034) at week 8. There were significant differences in between-group changes (total absorbency of pads used in 24 hours and total cost of night pads used). Both groups reported improved health-related quality of life. Analysis of qualitative data revealed 3 themes: resource use; quality of continence care; and system utility and limitations. A technological solution offering a standardized system of continence assessment provided benefit in terms of quality of care for residents and use of continence containment products; utility was validated by staff.

QUALITY CARE AND CONFLICTING RIGHTS AMONG RESIDENTS WITH DEMENTIA, FAMILIES, AND STAFF IN LONG-TERM CARE FACILITIES

Abstract Conflicting rights between residents with dementia and staff pose unique problems for quality of care in long-term care (LTC) facilities. Residents relying on staff for care may be afraid to express concerns. A disproportionate female (and often women of color) staff may be exposed to discrimination that stems from a resident’s loss of executive functioning and inability to control emotions. Family often find themselves somewhere in the middle. This study, thus, poses two research questions: (1) How do residents, families, and LTC staff understand their rights when conflicts arise between residents with dementia and staff?; (2) How can we leverage collective expertise of residents, families, and LTC staff to deliver a more holistic approach for addressing these conflicts? To answer these questions, I employed a multi-method qualitative design using semi-structured interviews (n=90) and participant observation (n=8 months). Building on legal consciousness theory—which explains how individuals invoke (or do not invoke) legal principles to define everyday experiences—findings revealed that staff rarely invoked legal framings to describe interactions whereas residents readily invoked rights rhetoric. Families mostly avoided rights rhetoric and instead focused on storytelling. All groups (residents, staff, and families) employed an array of emotional literacy and life experiences to navigate conflicts that coalesced around empathy. This paper concludes with research, policy, and practice suggestions for invoking principles of empathy to advance quality of care for residents with dementia by improving interactions among residents, staff, and family and workforce conditions for staff that flow from these interactions.

PRESIDENTIAL SYMPOSIUM: RACIAL AND ETHNIC HEALTH DISPARITIES ACROSS THE LONG-TERM SERVICES AND SUPPORTS CONTINUUM: NEED FOR POLICY AND ACTION

Abstract The pandemic further exacerbated racial and ethnic health disparities with BIPOC (Black, Indigenous and People of Color) communities experiencing significantly higher infection rates and higher hospitalization rates compared to White populations. Underlying medical conditions that disproportionately affect BIPOC populations (e.g., cardiovascular disease, diabetes, COPD) and social determinants of health (income, community and environmental factors, access to health care and job security) can account in large part for increased rates of morbidity and mortality. Within the long term services and supports (LTSS) continuum, health disparities exist in both who receives and provides care. The four papers in this Social Research Policy and Practice Presidential Symposium will highlight factors that result in health disparities across the LTSS continuum and propose possible policy and practice solutions to address the disparities. The first paper presented will be an overview of existing nursing home workforce issues that continue to impact disparities in the quality of resident care. The second paper presented examines nursing home resident quality of life disparities from a measurement perspective. The third paper will highlight issues on elder abuse and mistreatment of rural elders, American Indian and Alaskan Natives. The fourth paper will present recommendations from key stakeholders of the RAISE Family Caregiving Advisory Council on how to meet the needs of underrepresented groups (AAPI, BIPOC, Indigenous peoples) of family caregivers. Policy and practice solutions to reduce disparities will be discussed.

The Canadian Long-Term Care Sector Collapse from COVID-19: Innovations to Support People in the Workforce.

The COVID-19 pandemic rattled Canada's long-term care (LTC) sector by exacerbating the ingrained systemic and structural issues, resulting in tragic consequences for the residents, family members and LTC staff. At the core of LTC's challenges is chronic under-staffing, leading to lower quality of care for residents and higher degrees of moral distress among staff. A rejuvenation of the LTC sector to support its workforce is overdue. A group of diverse and renowned researchers from across Canada set out to implement innovative evidence-informed solutions in various LTC homes. Their findings call for immediate action from policy makers and LTC decision makers.

Nurses' experiences of an outreach interprofessional mental health service for nursing homes: a qualitative descriptive study.

Accessible SummaryWhat is known on the subject? Treatment and mental health care in familiar environments are beneficial for older people experiencing mental health issues. But there are not enough qualified and specialized nurses who can meet the complex needs of nursing home residents experiencing mental health issues.The University Hospital of Psychiatry Zurich, Switzerland, established an outreach interprofessional mental health service to foster the care for residents experiencing mental health issues in nursing homes. Based on existing studies, little can be said about whether nurses in nursing homes find these types of services helpful. What does this paper add to existing knowledge? Nurses in nursing homes caring for residents experiencing mental health issues felt relieved by having inclusive support from the interprofessional mental health service. Nurses appreciated the mental health team and felt accompanied and more confident in their daily work.Results showed that nurses wanted to be included in the care and treatment processes and to work as partners on an equal footing with the mental health team. What are the implications for practice? Outreach interprofessional mental health services for nursing homes should take into account nurses' views and professional experience, and value and respect their role as nurses.Outreach interprofessional mental health services for nursing homes should offer further training in psychiatric nursing, include an accessible contact person in the team, and develop clear processes and responsibilities. IntroductionOutreach interprofessional mental health services for nursing homes can increase the quality of care for residents experiencing mental health issues but research on how nurses in nursing homes experience such a service is lacking worldwide.AimTo describe how nurses experience the involvement of an outreach interprofessional mental health team in the care for older people experiencing mental health issues in nursing homes and to identify barriers to and facilitators of interprofessional collaboration.MethodQualitative descriptive analysis based on 13 semi‐structured interviews. Framework analysis and complex adaptive systems theory were applied.ResultsOne core theme with two main categories: Nurses experienced relief from burden through inclusive support provided by the mental health team. Main categories were feeling accompanied and confident as a nurse and partnership‐based collaboration.DiscussionResults showed for the first time that nurses felt supported by the mental health team and were encouraged to find new ways of coping with challenging situations.Implications for PracticeTo empower nurses, mental health teams should take into account nurses' perceptions in the treatment process, value and respect their role as nurses, transfer knowledge in both formal and informal settings, establish a steady and reliable contact person, and define processes and responsibilities.

Single-site employment (multiple jobholding) in residential aged care: A response to COVID-19 with wider workforce lessons.

ObjectiveThis study aimed to capture stakeholder views and issues arising from the implementation of the innovative single‐site employment guiding principles (SSE‐GP) that the Australian Government, in consultation with the sector, introduced into hot spot residential aged care facilities (RACFs) in July 2020 in response to COVID‐19.MethodsInterviews with 74 stakeholders around Australia were conducted in October–November 2020. Provider interviews included employees and managerial and human resources staff in profit and non‐profit services who did, and did not, have COVID‐19 outbreaks. Sector interviews included representatives from peak bodies, unions, government, academics, advocates, labour hire and registered training organisations.ResultsThere was broad but not total agreement on SSE‐GP's effectiveness. Beyond specific SSE‐GP feedback, six strategic workforce issues were identified. The quality of resident care was mixed, sometimes improved and sometimes diminished. The extent of employees' multiple jobholding surprised many providers, and rostering and unplanned absenteeism are a substantial strain for both providers and employees. Innovative work practices are often difficult for smaller providers lacking employment relations specialists. Future SSE‐GP is seen by larger providers as voluntary and organisation‐ rather than facility‐specific, and unions saw only mandated SSE‐GP as appropriate for future outbreaks. Last, all staff, management and executives had additional stress that placed their well‐being at risk.ConclusionsAlthough SSE‐GP revealed new and existing weaknesses in the Australian RACF workforce, the broad industry consultation and collaboration demonstrated that the sector can meet COVID‐19's urgent and complex challenges. The experience provided lessons for further workforce challenges that remain to be addressed.

Daily Variation in Nursing Home Staffing and Its Association With Quality Measures

Average staffing measures are a focus of nursing homes' quality assessments and reporting. They may, however, mask daily variation in staffing, additional information that could be important for understanding nursing home quality and relative ranking. To examine daily variation in staffing, its association with quality, and whether daily variation provides information regarding quality ranking of nursing homes over and above the information provided by average staffing levels. This quality improvement study included registered nurses (RNs) and certified nurse aide (CNAs) at 13 339 certified nursing homes throughout the United States during 2017 to 2018. Retrospective analyses of the Payroll-Based Journal, Medicare Cost Reports, and Nursing Home Care Compare were conducted. Data were analyzed from January 2017 to December 2018. Three measures of daily variation, ie, coefficient of variation (COV), total outlier days (TOD), and low outlier days (LOD), were calculated for RNs and CNAs. The association between these measures and quality rankings and other facility characteristics were evaluated. A total of 13 339 nursing homes were included in this study, with 9476 (71%) for-profit facilities. The mean (SD) hours-per-resident-day were 0.41 (0.29) for RNs and 2.16 (0.49) for CNAs, and a mean (SD) 55% (26%) of residents were Medicaid beneficiaries. Outcome measures were as follows: mean (SD) COV, 0.5 (0.6) for RNs and 0.1 (0.1) for CNAs; mean (SD) TOD, 220 (69) for RNs and 44 (45) for CNAs; and mean (SD) LOD, 116 (45) for RNs and 22 (24) for CNAs. All 3 variation measures, for both RNs and CNAs, were significantly associated with both the 5-Star Quality Measures (COV among RNs, -0.014 [95% CI, -0.021 to -0.007]; P < .001; COV among CNAs: -0.004 [95% CI, -0.006 to -0.003]; P < .001; TOD among RNs, -3.79 [95% CI, -4.59 to -2.99]; P < .001; TOD among CNAs, -2.52 [95% CI, -3.08 to -1.96]; P < .001; LOD among RNs, -2.46 [95% CI, -3.03 to -1.88]; P < .001; LOD among CNAs, -1.29 [95% CI, -1.58 to -0.99]; P < .001) and the 5-Star Survey rankings (COV among RNs,-0.026 [95% CI, -0.033 to -0.019]; P < .001; COV among CNAs: -0.006 [95% CI, -0.007 to -0.004]; P < .001; TOD among RNs, -5.10 [95% CI, -5.97 to -4.23]; P < .001; TOD among CNAs, -4.16 [95% CI, -4.77 to -3.55]; P < .001; LOD among RNs, -3.04 [95% CI, -3.65 to -2.44]; P < .001; LOD among CNAs, -1.97 [95% CI, -2.29 to -1.65]; P < .001) published in Nursing Home Care Compare. Low κ values, ranging from 0.23 to 0.63, indicated that the variation measures add information about ranking to the information provided by average staffing measure. These findings highlight the importance of reporting daily variation in staffing to improve understanding of the relationship between staffing and quality. They suggest that 2 facilities with the same average staffing achieve different quality of resident care and survey ratings in association with on the day-to-day variation in staffing. Measures of daily staffing may enhance the value of Nursing Home Care Compare for nursing homes and others engaged in quality improvement and consumers searching for high quality nursing homes.

Quality of care for residents who reside in the Aging in Place facilities in Hawaii: A family member perspective

Quality of care for residents who reside in the Aging in Place facilities in Hawaii: A family member perspective