Patient Care Technician Staffing and Outcomes Among US Patients Receiving In-Center Hemodialysis.

Importance: Dialysis patient care technicians (PCTs) play a critical role in US in-center hemodialysis (HD) care, but little is known about the association of PCT staffing with patient outcomes at US HD facilities. Objective: To estimate the associations of in-center HD patient outcomes with facility-level PCT staffing. Design, Setting, and Participants: This was a retrospective cohort study, with data analysis performed from March 2023 to January 2024. Data on US patients with end-stage kidney disease and their treatment facilities were obtained from the US Renal Data System. Participants included patients (aged 18-100 years) initiating in-center HD between January 1, 2016, and December 31, 2018, who continued receiving in-center HD for 90 days or more and had data on PCT staffing at their initial treating HD facility. Exposure: Facility-level patient-to-PCT ratios (number of HD patients divided by the number of PCTs reported by the treating facility in the prior year), categorized into quartiles (highest quartile denotes the highest PCT burden). Main Outcomes and Measures: Patient-level outcomes included 1-year patient mortality, hospitalization, and transplantation. Associations of outcomes with quartile of patient-to-PCT ratio were estimated using incidence rate ratios (IRRs) from mixed-effects Poisson regression, with adjustment for patient demographics and clinical and facility factors. Results: A total of 236 126 patients (mean [SD] age, 63.1 [14.4] years; 135 952 [57.6%] male; 65 945 [27.9%] Black; 37 777 [16.0%] Hispanic; 153 637 [65.1%] White; 16 544 [7.0%] other race; 146 107 [61.9%] with diabetes) were included. After full adjustment, the highest vs lowest quartile of facility-level patient-to-PCT ratio was associated with a 7% higher rate of patient mortality (IRR, 1.07; 95% CI, 1.02-1.12), a 5% higher rate of hospitalization (IRR, 1.05; 95% CI, 1.02-1.08), an 8% lower rate of waitlisting (IRR, 0.92; 95% CI, 0.85-0.98), and a 20% lower rate of transplant (IRR, 0.80; 95% CI, 0.71-0.91). The highest vs lowest quartile of patient-to-PCT ratio was also associated with an 8% higher rate of sepsis-related hospitalization (IRR, 1.08; 95% CI, 1.03-1.14) and a 15% higher rate of vascular access-related hospitalization (IRR, 1.15; 95% CI, 1.03-1.28). Conclusions and Relevance: These findings suggest that initiation of treatment in facilities with the highest patient-to-PCT ratios may be associated with worse early mortality, hospitalization, and transplantation outcomes. These results support further investigation of the impact of US PCT staffing on patient safety and quality of US in-center HD care.

Patient Care Technician Staffing in US Hemodialysis Facilities: An Ecological Study.

Rationale & Objective: Technicians caring for patients receiving dialysis play a critical, frontline role in the care of patients receiving dialysis in the United States. We sought to provide a comprehensive description and identify correlates of US in-center hemodialysis facility patient care technician staffing patterns. Study Design: This was an ecological study. Setting & Participants: US facilities providing hemodialysis and reporting patient care technician staffing, identified using the US Renal Data System. Exposures: Geography, year, and facility characteristics, including aggregated patient characteristics. Outcomes: The study outcome was facility-reported patient-to-patient care technician ratio. Analytical Approach: We examined patient-to-patient care technician ratios by US state and over time and also estimated the differences in patient-to-patient care technician ratios associated with facility characteristics, using robust regression with adjustment for facility-level covariates. Results: The median patient-to-patient care technician ratio among 6,862 US facilities in 2019 was 9.9 (25th-75th percentiles, 8.2-12.0). Median 2019 patient-to-patient care technician ratios varied substantially by US state and region. There was an overall decline (from 10.6 to 9.9) in median patient-to-patient care technician ratios from 2004 to 2019, whereas the percentage of positions that were unfilled increased (from 2.8% to 3.5%). After adjustment, large dialysis organization status (ß, -0.42; 95% CI, -0.61 to -0.23) and larger facility size (ß, -0.51; 95% CI, -0.68 to -0.33) were associated with lower patient-to-patient care technician ratios. Higher patient-to-registered nurse (ß, 0.80; 95% CI, 0.65-0.94) and patient-to-social worker (ß, 0.53; 95% CI, 0.37-0.70) ratios, presence of licensed vocational nurses or licensed practical nurses at the clinic (ß, 0.83; 95% CI, 0.53-1.12), and location in a poverty area (ß, 0.29; 95% CI, 0.13-0.44) were all associated with higher patient-to-patient care technician ratios. Aggregated patient characteristics of patients treated at the facilities were generally not associated with patient-to-patient care technician ratio after adjustment. Limitations: Limited causal inference and potential shifts in staffing after 2019. Conclusions: US dialysis facilities vary considerably in their patient care technician staffing by geography, over time, and by various facility characteristics. Further investigation of US patient care technician staffing is warranted and could lead to better, more stable dialysis staffing, improved staff and patient satisfaction, and higher quality of care.

In the United States, patient care technicians play an important role in hemodialysis care. Although ongoing staffing shortages and turnover among other hemodialysis care providers have been described, little is known about US patient care technician staffing. Examining national data reported by dialysis facilities, we found variability in patient care technician staffing by geography, over time (with fewer patients per patient care technician in more recent years), and by various facility characteristics. This information can be used to target staff recruitment and retention interventions at facilities where patient care technician staffing may be more challenging.

A Collaborative Approach to Improving Care Outcomes for Residents in Assisted Living.

Purpose: Assisted Living (AL) residents are embedded in "care convoys" comprised of a dynamic network of formal and informal care partners. Using the convoys of care model-a multi-level framework connecting care convoy properties to resident outcomes-we examined healthcare management and communication between convoy members. We recommend strategies to engage primary care in supporting collaboration, communication, and consensus-building for older adults and their convoys. Methods: Data were collected from the longitudinal study, Convoys of Care: Developing Collaborative Care Partnerships in AL. Fifty residents and their care convoy members (N = 169) were followed in eight AL homes in Georgia over 2 years. Original data were analyzed using Grounded Theory Methods of qualitative data, including formal and informal interviewing, participant observation, and record review. Results: The convoys of care model provide an innovative perspective that will assist providers in supporting AL residents and their care partners to achieve better care outcomes. Findings demonstrate the utility of understanding the structure and function of social resources and implications for improving healthcare outcomes. Conclusion: This research informs the work of physicians and mid-level providers with patients in AL by providing strategies to uncover specific social determinants of health. Recommendations for use in patient encounters are enumerated.

Work Experiences of the Interdisciplinary Dialysis Workforce in the United States: A Cross-Sectional Survey.

INTRODUCTION: Suboptimal dialysis care may be in part due to staff issues such as job dissatisfaction, burnout, work overload, high staff turnover, and inconsistent training. Here, we leveraged data collected in a recent national survey to provide an initial, comprehensive description of current work experiences of US dialysis care providers. METHODS: We conducted a cross-sectional survey of 1,240 active US dialysis clinic staff members (physicians, advanced practice providers, nurse managers/clinic coordinators, nurses, social workers, dietitians, and patient care technicians), who were recruited via emails to society membership lists. Respondents were asked about a wide variety of work experiences, including job satisfaction, professional fulfillment, and burnout (Stanford Professional Fulfillment Index), work culture, experiences of hostility and violence, and self-reported medical errors. Responses were summarized overall and compared by clinic role. RESULTS: Most of the survey respondents, representing all 50 US states, were aged 35-49 years (58.3%) or ≥50 years (23.5%), female (60.7%), and white (59.8%; 23.1% black, and 10.0% Asian); 82.1% had been in their current role for at least 1 year. Most US dialysis staff responding to our survey reported being generally satisfied with their jobs (mean rating of 7.9 on 0-10 scale), but only 54.4% met criteria for professional fulfillment, and 32.8% met criteria for burnout, driven by high scores in the work exhaustion domain. Related issues, including high workloads, lack of respect (including experiences of violence and hostility), lack of autonomy, and suboptimal patient environments (in terms of both safety and patient centeredness), were commonly reported among dialysis care providers, although their prevalence often differed by provider type. CONCLUSION: Our results suggest that the dialysis workforce may be at a critical point. Preventing further staff burnout, which could lead to even greater staffing shortages and worse working conditions among those who continue to provide dialysis care, is essential.

Understanding Capacity and Optimizing Meaningful Engagement among Persons Living with Dementia.

Meaningful engagement is a key dimension of quality of life among persons living with dementia, yet little is known about how to best to promote it. Guided by grounded theory methods, we present analysis of data collected over a 1-year period in four diverse assisted living (AL) communities as part of the study, "Meaningful Engagement and Quality of Life among Assisted Living Residents with Dementia." Our aims are to: (a) learn how meaningful engagement is negotiated among AL residents with dementia and their care partners; and (b) identify how to create these positive encounters. Researchers followed 33 residents and 100 care partners (formal and informal) and used participant observation, resident record review, and semi-structured interviews. Data analysis identified "engagement capacity" as central to the negotiation of meaningful engagement. We conclude that understanding and optimizing the engagement capacities of residents, care partners, care convoys, and settings, are essential to creating and enhancing meaningful engagement among persons living with dementia.

Professional Fulfillment, Burnout, and Turnover Intention Among US Dialysis Patient Care Technicians: A National Survey.

RATIONALE & OBJECTIVE: High professional fulfillment and low burnout and staff turnover are necessary for a stable dialysis workforce. We explored professional fulfillment, burnout, and turnover intention among US dialysis patient care technicians (PCTs). STUDY DESIGN: Cross-sectional national survey. SETTING & PARTICIPANTS: National Association of Nephrology Technicians/Technologists (NANT) members in March-May 2022 (N=228; 42.6% aged 35-49 years, 83.9% female, 64.6% White, 85.3% non-Hispanic). EXPOSURE: Likert-scale items (range, 0-4) related to professional fulfillment and 2 domains of burnout (work exhaustion and interpersonal disengagement) and dichotomous items related to turnover intention. ANALYTICAL APPROACH: Summary statistics (percentages, means, medians) were calculated for individual items and average domain scores. Burnout was defined by combined work exhaustion and interpersonal disengagement scores of≥1.3 and professional fulfillment by a score≥3.0. RESULTS: Most respondents (72.8%) worked ≥40 hours per week. Overall scores for work exhaustion, interpersonal disengagement, and professional fulfillment (median [IQR]) were 2.3 (1.3-3.0), 1.0 (0.3-1.8), and 2.6 (2.0-3.2), respectively; 57.5% reported burnout, and 37.3% reported professional fulfillment. Important contributors to burnout and professional fulfillment included salary (66.5%), supervisor support (64.0%), respect from other dialysis staff (57.8%), sense of purpose about work (54.5%), and hours worked per week (52.9%). Only 52.6% reported that they plan to be working as a dialysis PCT in 3 years. Free text responses reinforced perceived excessive work burden and lack of respect. LIMITATIONS: Limited generalizability to all US dialysis PCTs. CONCLUSIONS: More than half of dialysis PCTs reported burnout, driven by work exhaustion; only about one-third reported professional fulfillment. Even among this relatively engaged group of dialysis PCTs, only half intended to continue working as PCTs. Because of the critical, frontline role of dialysis PCTs in the care of patient receiving in-center hemodialysis, strategies to improve morale and reduce turnover are imperative.

The Impact of COVID-19 on the Person-Centered Care Practices in Nursing Homes.

The COVID-19 pandemic has had a significant impact on long-term care residents, family, and staff. Nursing homes are facing persistent challenges such as staff shortage, lack of personal protective equipment (PPE), and staff experiencing mental health issues including burnout. COVID-19 precautions may have made implementing person-centered care (PCC) in nursing homes more difficult. This report provides a descriptive analysis of perceived COVID-19 impact on the PCC practice in nursing homes. Surveys (N = 379) were collected from 11 nursing homes across Georgia. PCC practice barriers include reduced choice for residents, staff anxiety related to COVID-19 precautions, increased prevalence of short-staffing, and expanded duties for direct care workers. Facilitators for PCC were also present and included staff engagement, the provision of mental health resources, supervisor support, and empowerment of staff. Applied practice and research to address these barriers and expand implementation of facilitators is needed.

Professional certification and earnings of health care workers in low social closure occupations.

There has been rapid growth in professional certifications in the health care sector, but little is known about the rewards to workers for attaining professional certifications, especially in low social closure occupations where the barriers to entry (e.g., higher education, degrees, licensure) are relatively limited. In this study, we focus on the attainment and rewards for professional certifications in four health care occupations - personal care aides, medical transcriptionists, medical assistants, and community health workers - where certification is generally not required by state or federal regulation but may be attractive to employers. Using the Current Population Survey (IPUMS CPS) from 2015 to 2020, we find that workers of color have significantly lower odds of attaining a certification, while women are 1.2 times more likely than men to an earn a certification. On average, workers who have earned a professional certification have weekly earnings that are 4.8% higher than workers who do not have a certification. Men experience the largest increase in weekly earnings (11.3%) when they have a professional certification as compared to those without, while women experience lower gains from professional certification (3.8%). Black and Hispanic workers experience modest rewards for certification (weekly earnings that are 1.2% and 5% higher, respectively) that are lower than the rewards gained by white workers (6% higher weekly earnings). Our findings suggest that professional certifications may have modest benefits for workers, but professional certifications often come with significant costs for individuals. Strategies for reducing inequality in the return to credentials and for improving job quality in the care sector are discussed.

Career Ladders for Medical Assistants in Primary Care Clinics.

BACKGROUND: This study examines the use of career ladders for medical assistants (MAs) in primary care practices as a mechanism for increasing wages and career opportunity for MAs. A growing body of research on primary care suggests that successful expansion of support staff roles such as MAs may have positive organizational and quality of care outcomes, but little is known about worker outcomes. OBJECTIVE: Evaluate the effectiveness of career ladders in improving wages and career opportunity among MAs. DESIGN: We use a mixed-methods design to evaluate the impact of career ladders on MA job quality. PARTICIPANTS: We draw on interview data collected from 115 key informants at four large health systems (ranging from 24 to 29 clinics each), and we analyze wage and employment data for MAs from primary care clinics in the four health systems in the sample. APPROACH: We describe the MA career ladder context and infrastructure within primary care clinics and evaluate the rewards to MAs for participation in the career ladder programs. KEY RESULTS: The expanded roles within career ladders for MAs focused on the following four clinical and educational areas: panel management and care coordination, EHR documentation support, supporting delivery of person-centered care, and supervision and training. The three primary components of the career ladder infrastructure were training and education for MAs and providers, credentialing and certification for MAs, and differentiated job levels for MAs. The use of career ladders in the four large health systems in our case study sample resulted in yearly income increases ranging from $3000 to $10,000 annually. CONCLUSION: Investing in career ladders in primary care clinics can improve MA job quality while also potentially addressing issues of equity, efficiency, and quality in the health care sector.

Redesigning the Role of Medical Assistants in Primary Care: Challenges and Strategies During Implementation.

Efforts to reform primary care increasingly focus on redesigning care in ways that utilize nonprovider staff such as medical assistants (MAs), but the implementation of MA role redesign efforts remains understudied in the U.S. health care literature. This article draws on rich, longitudinal case study data collected from four health care systems across the United States to examine critical challenges in the planning, implementation, and early sustainment of MA role redesign efforts in primary care. During the planning period, challenges included recruitment of highly trained MAs, compliance with organizational and state regulations regarding MA scope of practice, provision of consistent training across primary care clinics, and creation of career ladders that provided tiered compensation for MAs. During active implementation, challenges included provider training and preventing MA burnout. Strategies for addressing challenges in MA role redesign efforts are discussed, as well as early sustainment of program practices and organizational policies.

Where Policy Meets Practice: Employer Perspectives on Scheduling and Hours for Home Care Aides.

In a context of growing demand for home-based direct care services, the need to retain direct care workers (DCWs) is clear. The Patient Protection and Affordable Care Act, changes to the Fair Labor Standards Act, and state-level changes in Medicaid support for home-based care together have affected agencies that hire DCWs, with implications for an issue that affects worker satisfaction: scheduling. Many home-based aides employed by agencies cannot count on consistent or sufficient hours. Hours shortfall and instability have been recognized as important issues for retail and restaurant workers, but focused on less for care aides. This study uses semistructured interviews with agency representatives to examine these issues from an employer perspective, with a focus on how the competing influences of health care, labor, and employment policy shape scheduling and a review of how recommendations for changes in policy and practice in other sectors might apply to home care.

Maneuvering Together, Apart, and at Odds: Residents' Care Convoys in Assisted Living.

Objectives: Frail and disabled individuals such as assisted living residents are embedded in "care convoys" comprised of paid and unpaid caregivers. We sought to learn how care convoys are configured and function in assisted living and understand how and why they vary and with what resident and caregiver outcomes. Method: We analyzed data from a qualitative study involving formal in-depth interviews, participant observation and informal interviewing, and record review. We prospectively studied 28 residents and 114 care convoy members drawn from four diverse assisted living communities over 2 years. Results: Care convoys involved family and friends who operated individually or shared responsibility, assisted living staff, and multiple external care workers. Residents and convoy members engaged in processes of "maneuvering together, apart, and at odds" as they negotiated the care landscape routinely and during health crises. Based on consensus levels, and the quality of collaboration and communication, we identified three main convoy types: cohesive, fragmented, and discordant. Discussion: Care convoys clearly shape care experiences and outcomes. Identifying strategies for establishing effective communication and collaboration practices and promoting convoy member consensus, particularly over time, is essential to the creation and maintenance of successful and supportive care partnerships.

Exposing the Backstage: Critical Reflections on a Longitudinal Qualitative Study of Residents' Care Networks in Assisted Living.

In this article, we analyze the research experiences associated with a longitudinal qualitative study of residents' care networks in assisted living. Using data from researcher meetings, field notes, and memos, we critically examine our design and decision making and accompanying methodological implications. We focus on one complete wave of data collection involving 28 residents and 114 care network members in four diverse settings followed for 2 years. We identify study features that make our research innovative, but that also represent significant challenges. They include the focus and topic; settings and participants; scope and design complexity; nature, modes, frequency, and duration of data collection; and analytic approach. Each feature has methodological implications, including benefits and challenges pertaining to recruitment, retention, data collection, quality, and management, research team work, researcher roles, ethics, and dissemination. Our analysis demonstrates the value of our approach and of reflecting on and sharing methodological processes for cumulative knowledge building.

Evaluation of a Laughter-based Exercise Program on Health and Self-efficacy for Exercise.

Background: Despite health benefits of physical activity (PA) and risks of physical inactivity, many older adults do not accumulate sufficient levels of PA to achieve associated health benefits. Lack of PA enjoyment may be a barrier to PA participation. Combining simulated laughter and PA for strength, balance, and flexibility is a potential solution for helping older adults maintain independence in activities of daily living through enjoyable participation in PA. Purpose of the study: The purpose of this study is to assess whether combining simulated laughter exercises with a moderate-intensity strength, balance, and flexibility PA program (i.e., LaughActive) increases participation in PA, health, and self-efficacy for PA among older adults residing in 4 assisted living facilities (ALFs). Design and methods: The 12-week wait list control pilot study used pre- and 6-week post-intervention comparisons within and between groups identified by paired sample t-test results among those who participated in twice-weekly LaughActive classes (n = 27). Results: Significant improvements (p < .05-.10) were observed in mental health (SF-36v2), aerobic endurance (2-minute step test), and self-efficacy for exercise (OEE). Implications: PA programs that elicit positive emotions through simulated laughter have the potential to improve health, physical performance, and self-efficacy for PA among older adults and may positively influence participant adherence.

Library and information services: impact on patient care quality.

PURPOSE: The purpose of this paper is to explore library and information service impact on patient care quality. DESIGN/METHODOLOGY/APPROACH: A large-scale critical incident survey of physicians and residents at 56 library sites serving 118 hospitals in the USA and Canada. Respondents were asked to base their answers on a recent incident in which they had used library resources to search for information related to a specific clinical case. FINDINGS: Of 4,520 respondents, 75 percent said that they definitely or probably handled patient care differently using information obtained through the library. In a multivariate analysis, three summary clinical outcome measures were used as value and impact indicators: first, time saved; second, patient care changes; and third, adverse events avoided. The outcomes were examined in relation to four information access methods: first, asking librarian for assistance; second, performing search in a physical library; third, searching library's web site; or fourth, searching library resources on an institutional intranet. All library access methods had consistently positive relationships with the clinical outcomes, providing evidence that library services have a positive impact on patient care quality. ORIGINALITY/VALUE: Electronic collections and services provided by the library and the librarian contribute to patient care quality.

An evaluation of state-based support-for-service programs targeting nurse faculty.

AIM: The aim of the study was to assess how state-based support-for-service (SFS) programs are used by deans and directors of nursing programs and to evaluate their perceived impact. BACKGROUND: Given projected nurse faculty shortages, stakeholders are looking for ways to address the maldistribution and shortage of nurse faculty. One state-level strategy is the implementation of loan repayment and scholarship programs, which incentivize individuals with, or currently pursuing, graduate degrees to become or remain nurse faculty. METHOD: This study used a mixed-method and multilevel approach to assess the impact of SFS programs in seven states. RESULTS: Programs are perceived to affect both recruitment and retention of faculty and play a role in increasing the educational qualifications of current nurse faculty. CONCLUSION: Nurse educators need to be aware of SFS programs and how best to use them to support nurse faculty.

Retaining experts: retirement plans of clinical laboratory professionals.

A survey to assess the retirement plans of clinical laboratory professionals (CLP) and the factors that would influence those plans was distributed to members of the American Society for Clinical Laboratory Science (ASCLS) in May, 2012. A majority of respondents (65%) between 50-62 years indicated that there was a greater than 50% chance they would be working after age 62. Only 15.8% of the respondents thought that there was a greater than 50% chance that they would be working full time after they retired from their current job. The retirement option selected most often by respondents was part time work. This was true for respondents in all age groups and job functions. The greatest personal influence on retirement plans was concern about health issues. The results indicate that, if employers can provide part time options, older workers may stay in the workforce as long as they are healthy.

Retaining experts: retention incentives of clinical laboratory professionals.

A survey of members of the American Society for Clinical Laboratory Science (ASCLS) was taken in May, 2012 to study workplace incentives and personal factors that could encourage clinical laboratory professionals (CLP) to continue working past retirement eligibility. Benefits, compensation, and opportunity for part-time work were key retention incentives identified by CLP in all age and job function groups. Career stage was shown to play a significant role in how CLP rated the importance of several retirement incentives, suggesting that age differences exist in workplace factors and personal motivators for continuing to work. There are also differences among practitioners, administrators, and educators in how they view incentives for working past retirement eligibility. Results of the study may help laboratory administrators advocate for workplace changes important to retaining staff of varying age and job function.

Frontline health care workers and perceived career mobility: do high-performance work practices make a difference?

BACKGROUND: The use of high-performance work practices (HPWPs) related to career development (e.g., tuition remission, career ladders) is becoming more common in health care organizations, where skill shortages and concerns about quality of care have led to increasing investment in the frontline health care workforce. However, few studies have examined the effectiveness of these policies in shaping the career trajectories of health care workers. PURPOSES: The aim of this study is to examine how HPWPs that focus on career development are related to an individuals' perceived mobility with their current employer. We will also examine the relationships between perceived mobility, job satisfaction, and turnover intent. METHODOLOGY/APPROACH: We use confirmatory factor analysis and structural equation modeling to examine the relationships between HPWPs and perceived mobility in a sample of 947 frontline health care workers in 22 health care organizations across the United States. FINDINGS: The findings suggest that tuition remission and educational release time positively predict perceived mobility. Measures of perceived organizational support in one's current position (e.g., financial rewards, workload, and autonomy) and perceived supervisor support for career development are also significant predictors of perceived mobility. Finally, perceived mobility is a significant predictor of job satisfaction and intent to stay with current employer. PRACTICE IMPLICATIONS: Our findings suggest that HPWPs related to career development may be effective tools in improving workers' assessments of their own career potential and improving overall job satisfaction of frontline health care workers. Consequently, HPWPs related to career development may help employers both retain valuable workers and fill worker shortages.