The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study).

BACKGROUND: This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations. METHODS: Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators. RESULTS: Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators. CONCLUSIONS: This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts.

Assessing Associations Between Health Information Technology Maturity and Nursing Home Survey Deficiencies.

One in three nursing home (NH) residents experience adverse events. One strategy for safer NH care is health information technology (HIT). Two national NH surveys measuring HIT maturity were administered in 2020 (N = 719) and 2021 (N = 312). Quarterly NH survey deficiencies from the same years were linked to HIT maturity surveys. Descriptive statistics and logistic regression were used in analysis. NHs were of similar size and location, with more for-profit facilities. Most (67.5% and 61.9%, respectively) NH administrators reported having capabilities to share data internally within their facility, and not externally. Mean HIT maturity scores increased from Year 1 to Year 2. Over 2 years, 5,406 deficiencies were reported, mostly (31.3%) for nutrition and dietary deficiencies. There were negative associations between HIT maturity and deficiency scope. With a 1-unit increase in HIT maturity, relative risk of widespread scope decreased by 14%. Among covariates, bed size, staffing, and year were significant factors associated with deficiency scope. [Journal of Gerontological Nursing, 50(1), 8-14.].

Scoping review: Positive and negative impact of technology on clinicians.

BACKGROUND: Unnecessary electronic health record (EHRs) documentation burden and usability issues have negatively impacted clinician well-being (e.g., burnout and moral distress). PURPOSE: This scoping review was conducted by members from three expert panels of the American Academy of Nurses to generate consensus on the evidence of both positive and negative impact of EHRs on clinicians. METHODS: The scoping review was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews guidelines. RESULTS: The scoping review captured 1,886 publications screened against title and abstract 1,431 excluded, examined 448 in a full-text review, excluded 347 with 101 studies informing the final review. DISCUSSION: Findings suggest few studies that have explored the positive impact of EHRs and more studies that have explored the clinician's satisfaction and work burden. Significant gaps were identified in associating distress to use of EHRs and minimal studies on EHRs' impact on nurses. CONCLUSION: Examined the evidence of HIT's positive and negative impacts on clinician's practice, clinicians work environment, and if psychological impact differed among clinicians.

Calling all nurses-Now is the time to take action on improving the quality of care in nursing homes.

For a number of decades, nurses have raised concerns about nursing-related issues in nursing homes (NH) such as inadequate registered nurse (RN) staffing, insufficient RN and advanced practice registered nurse (APRN) gerontological expertise, and lack of RN leadership competencies. The NASEM Committee on the Quality of Care in Nursing Homes illuminated the long-standing issues and concerns affecting the quality of care in nursing homes and proposed seven goals and associated recommendations intended to achieve the Committee's vision: Nursing home residents receive care in a safe environment that honors their values and preferences, addresses goals of care, promotes equity, and assesses the benefits and risks of care and treatments. This paper outlines concrete and specific actions nurses and nursing organizations can take to ensure the recommendations are implemented.

A qualitative study exploring nursing home care environments where nurse practitioners work.

Research is needed to support the growing nurse practitioner workforce to assure higher quality care for older adults in nursing homes. Nursing homes with optimal care environments that support nurse practitioner roles, increased visibility, independence, and relationships are better positioned to support care of older adults. This study reports findings of thirteen qualitative interviews with nurse practitioners to explore facets of nursing home care environments and adapt a tool to measure care environments. Our team incorporated deductive and inductive coding to identify three major emerging themes impacting care environments: 1) nurse practitioner practice in nursing homes, 2) overall goals of practice, 3) workplace challenges. Themes were derived from seven overarching categories and 33 codes describing aspects of NH care environment important to nurse practitioners. Some of the most highly important survey items measured nurse practitioner and physician relationships. Less important items measured relationships between nurse practitioners and administration.

Designing clinical indicators for common residential aged care conditions and processes of care: the CareTrack Aged development and validation study.

BACKGROUND: People who live in aged care homes have high rates of illness and frailty. Providing evidence-based care to this population is vital to ensure the highest possible quality of life. OBJECTIVE: In this study (CareTrack Aged, CT Aged), we aimed to develop a comprehensive set of clinical indicators for guideline-adherent, appropriate care of commonly managed conditions and processes in aged care. METHODS: Indicators were formulated from recommendations found through systematic searches of Australian and international clinical practice guidelines (CPGs). Experts reviewed the indicators using a multiround modified Delphi process to develop a consensus on what constitutes appropriate care. RESULTS: From 139 CPGs, 5609 recommendations were used to draft 630 indicators. Clinical experts (n = 41) reviewed the indicators over two rounds. A final set of 236 indicators resulted, mapped to 16 conditions and processes of care. The conditions and processes were admission assessment; bladder and bowel problems; cognitive impairment; depression; dysphagia and aspiration; end of life/palliative care; hearing and vision; infection; medication; mobility and falls; nutrition and hydration; oral and dental care; pain; restraint use; skin integrity and sleep. CONCLUSIONS: The suite of CT Aged clinical indicators can be used for research and assessment of the quality of care in individual facilities and across organizations to guide improvement and to supplement regulation or accreditation of the aged care sector. They are a step forward for Australian and international aged care sectors, helping to improve transparency so that the level of care delivered to aged care consumers can be rigorously monitored and continuously improved.

A Call to Address RN, Social Work, and Advanced Practice Registered Nurses in Nursing Homes: Solutions From the Missouri Quality Initiative.

BACKGROUND: US nursing homes (NHs) have struggled to overcome a historic pandemic that laid bare limitations in the number and clinical expertise of NH staff. PROBLEM: For nurse staffing, current regulations require only one registered nurse (RN) on duty 8 consecutive hours per day, 7 days per week, and one RN on call when a licensed practical/vocational nurse is on duty. There is no requirement for a degreed or licensed social worker, and advanced practice registered nurses (APRNs) in NHs cannot bill for services. APPROACH: It is time to establish regulation that mandates a 24-hour, 7-day-a-week, on-site RN presence at a minimum requirement of 1 hour per resident-day that is adjusted upward for greater resident acuity and complexity. Skilled social workers are needed to improve the quality of care, and barriers for APRN billing for services in NHs need to be removed. CONCLUSIONS: Coupling enhanced RN and social work requirements with access to APRNs can support staff and residents in NHs.

Value Propositions for Health Information Exchange Toward Improving Nursing Home Hospital Readmission Rates.

The importance of health information technology use in nursing home (NH) care delivery is a major topic in research exploring methods to improve resident care. Topics of interest include how technology investments, infrastructure, and work-force development lead to better methods of nursing care delivery and outcomes. Value propositions, including perceived benefits, incentives, and system changes recognized by end-users, are important resources to inform NH leaders, policymakers, and stakeholders about technology. The purpose of the current research was to identify and disseminate value propositions from a community of stakeholders using a health information exchange (HIE). Researchers used a nominal group process, including 49 individual stakeholders participating in a national demonstration project to reduce avoidable hospitalizations in NHs. Stakeholders identified 41 total anticipated changes from using HIE. Ten stakeholder types were perceived to have experienced the highest impact from HIE in areas related to resident admissions, communication, and efficiency of care delivery. [Journal of Gerontological Nursing, 48(1), 15-20.].

Usability Evaluation of a Smartphone Medication Reminder Application in Patients Treated With Short-term Antibiotic.

Medication adherence is poor in persons with chronic disease, especially in those with multiple chronic diseases, one of which is a psychological disorder. Social support, medication education, and external reminders have been identified as facilitators of adherence. Mobile health applications have the potential to enhance adherence; however, it is unknown if publicly available applications are user-friendly and useful. We aimed to examine the usability and feasibility of the "MediSafe" medication reminder application in adults with diarrhea-predominant irritable bowel syndrome undergoing short-term antibiotic therapy and a "Medfriend" from their social support network (N = 14). A mixed-methods study was conducted. All patient participants used the MediSafe application daily for 14 days. Ease of use, ease of learning, and satisfaction scales were rated highest by both patient participants and Medfriends, whereas usefulness was rated lowest by both groups, with Medfriends' usefulness rating significantly lower than that of patient participants. Telephone interviews identified patient participants found the application instrumental in facilitating medication adherence, and Medfriends viewed themselves as active participants in the patient participants' care. The MediSafe medication reminder application is easy to use and accepted by both patients and their designated Medfriend. The MediSafe is instrumental in facilitating short-term antibiotic adherence and social support engagement.

Examining Social Networks in Text Messages About Nursing Home Resident Health Status.

Social network analysis (SNA) uses quantitative methods to analyze relationships between people. In the current study, SNA was applied in two nursing homes (NHs) to describe how health care teams interact via text messages. Two data sources were used: (a) a Qualtrics® survey completed by advanced practice RNs containing resident transfer data, and (b) text messages from a secure platform called Mediprocity™. SNA software was used to generate a visual representation of the social networks and calculate quantitative measures of network structure, including density, clustering coefficient, hierarchy, and centralization. Differences were found in the low and high transfer rate NHs for all SNA measures. Staff in the NH with low transfer rate had greater decision-making interactions, higher information exchange rates, and more individuals communicating with each other compared to the high transfer rate NH. SNA can be applied to examine communication patterns found in text messages occurring around the time of NH resident transfers. [Journal of Gerontological Nursing, 47(7), 16-22.].

Differences in Care Provided in Urban and Rural Nursing Homes in the United States: Literature Review.

Despite evidence acknowledging disadvantages in care provided to older adults in rural nursing homes (NHs) in the United States, since 2010, no literature review has focused on differences in care provided in urban versus rural NHs. In the current study, we examined these differences by searching U.S. English-language peer-reviewed articles published after 2010 on differences in care quality in urban and rural NHs. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and used the Newcastle-Ottawa Scale for quality appraisal. We conducted full-text abstraction of 56 (of 286) articles, identifying 10 relevant studies. Metric specification of urban/rural location varied, and care quality measures were wide-ranging, making it difficult to interpret evidence. Limited evidence supported that rural NHs, compared to urban NHs, provided sparse mental health support and limited access to hospice care after controlling for facility and resident characteristics. Our review highlights the need for more research examining differences in quality of care between urban and rural NHs and raises several issues in current research examining urban/rural NH differences where future work is needed. [Journal of Gerontological Nursing, 47(12), 48-56.].

Correction to: Forecasting Content and Stage in a Nursing Home Information Technology Maturity Instrument Using a Delphi Method.

The original article unfortunately contained a mistake.

Forecasting Content and Stage in a Nursing Home Information Technology Maturity Instrument Using a Delphi Method.

Health information technology capabilities in some healthcare sectors, such as nursing homes, are not well understood because measures for information technology uptake have not been fully developed, tested, validated, or measured consistently. The paper provides a report of the development and testing of a new instrument measuring nursing home information technology maturity and stage of maturity. Methods incorporated a four round Delphi panel composed of 31 nursing home experts from across the nation who reported the highest levels of information technology sophistication in a separate national survey. Experts recommended 183 content items for 27 different content areas specifying the measure of information technology maturity. Additionally, experts ranked each of the 183 content items using an IT maturity instrument containing seven stages (stages 0-6) of information technology maturity. The majority of content items (40% (n = 74)) were associated with information technology maturity stage 4, corresponding to facilities with external connectivity capability. Over 11% of the content items were at the highest maturity stage (Stage 5 and 6). Content areas with content items at the highest stage of maturity are reflected in nursing homes that have technology available for residents or their representatives and used extensively in resident care. An instrument to assess nursing home IT maturity and stage of maturity has important implications for understanding health service delivery systems, regulatory efforts, patient safety and quality of care.

Qualitative Validation of the Nursing Home IT Maturity Staging Model.

The goal of the current study was to qualitatively explore issues of validity, specificity, and sensitivity regarding the nursing home (NH) information technology (IT) maturity survey and staging model. Participants who completed the NH IT maturity survey were recruited during pilot testing of the survey and staging model. Cognitive interviewing was used to collect qualitative data. Findings indicate the NH IT maturity survey and staging model is a straightforward and acceptable instrument. Every participant in our study agreed with the IT maturity stage assigned to their facility, based on their total score on the IT maturity survey. However, some participants were not sure how to answer some questions on the survey because they did not have in-depth knowledge of IT processes that took place outside of their NH facility and others experienced difficulty interpreting items because their NH facility was in a time of transition. The next step in development is quantitative psychometric testing and use of the instrument in a 3-year national study. [Journal of Gerontological Nursing, 46(7), 47-54].

Exploring Resident Care Information Technology Use and Nursing Home Quality.

A wide array of sophisticated information technology (IT) systems are being used in nursing home (NH) resident care to improve quality. The purpose of the current study was to explore differences in NH IT sophistication, a comprehensive measure of adoption, used in resident care processes based on facility characteristics over 4 consecutive years and to examine the impact on select long-stay NH quality measures. Results indicate IT systems used in resident care are becoming increasingly sophisticated. NH bed size, type of ownership, and location were significant predictors of IT score in areas related to resident care. Results also suggest that as electronic clinical processes and documents increase (e.g., incident reporting, nursing flowsheets, care planning) in resident care, more falls with injury are detected. Continued assessments of NH IT sophistication are important as the impact of technology on quality continues to be evaluated. [Journal of Gerontological Nursing, 46(4), 15-20.].

The Imperative of Solving Nurses' Usability Problems With Health Information Technology.

BACKGROUND: Health information technology (IT) usability issues are a key concern for nurse executives and nurses. OBJECTIVES: The aims of this study are to understand usability pain points faced by nurses regarding the use of health IT, identify their impact and importance, discuss responsibilities, and develop possible solutions to improve the health IT-user experience for nurses. METHODS: Twenty-seven experts were interviewed including nursing leaders, informaticists, executives, engineers, researchers, and human factors experts across acute care, long-term care, and vendor settings. Semistructured questions guided the interviews, and content analysis was used to identify themes. RESULTS: Four themes emerged: 1) user experience pain points, 2) importance of the issues, 3) the responsibility gap, and 4) acting on usability issues. CONCLUSION: Nurses continue to endure significant health IT-usability issues that negatively impact patients, nurses, and healthcare organizations. Solutions include enhancing the voice of nursing at the national and local levels, creating a digital strategy for nursing, providing incentives to improve usability in health IT, and accelerating the understanding of nurses' work intended to inform and translate nurses' work into health IT design.

Analyzing Change in Nursing Home Information Technology Sophistication: A 2-Year Survey.

Nursing home (NH) health information technology (IT) is becoming more prevalent across the country. Currently, a national sample of NHs is being surveyed for 3 consecutive years to determine trends in NH IT sophistication (e.g., measures of IT capabilities, extent of IT use, IT integration with internal and external stakeholders). IT sophistication is measured in resident care, clinical support, and administrative activities. The current article provides details of the differences in NH IT sophistication reported by administrators completing Year 1 and Year 2 surveys. IT in clinical support (i.e., laboratory, pharmacy, and radiology) had the greatest differences. This difference is expected because these areas typically require external contracts, making it dificult to fit IT with existing workflows, which is important for sustained adoption. [Journal of Gerontological Nursing, 43(1), 17-21.].

Assessment of Fall Characteristics From Depth Sensor Videos.

Falls are a major source of death and disability in older adults; little data, however, are available about the etiology of falls in community-dwelling older adults. Sensor systems installed in independent and assisted living residences of 105 older adults participating in an ongoing technology study were programmed to record live videos of probable fall events. Sixty-four fall video segments from 19 individuals were viewed and rated using the Falls Video Assessment Questionnaire. Raters identified that 56% (n = 36) of falls were due to an incorrect shift of body weight and 27% (n = 17) from losing support of an external object, such as an unlocked wheelchair or rolling walker. In 60% of falls, mobility aids were in the room or in use at the time of the fall. Use of environmentally embedded sensors provides a mechanism for real-time fall detection and, ultimately, may supply information to clinicians for fall prevention interventions. [Journal of Gerontological Nursing, 43(7), 13-19.].