A Fresh Look at the Nursing Home Workforce Crisis: Transforming Nursing Care Delivery Models.

The current State of the Science Commentary focuses on workforce challenges in the nursing home (NH) setting that lie within the purview of professional nursing-what professional nurses can do to promote high-quality person-centered care within a context of existing resources-individually and broadly across the collective profession. Historically, three models of care delivery have characterized the way in which nursing care is organized and delivered in different settings: primary nursing, functional nursing, and team nursing. Based on the existing evidence, we call for scientific leadership in the redesign, testing, and implementation of a nursing care delivery model that operationalizes relationship-centered team nursing. This integrative model incorporates successful evidence-based approaches that have the potential to improve quality of care, resident quality of life, and staff quality of work life: clear communication, staff empowerment, coaching styles of supervision, and family/care partner involvement in care processes. In addition to the needed evidence base for NH care delivery models, it is imperative that educational programs incorporate content and clinical experiences that will enable the future nursing workforce to fill the leadership gap in NH care delivery. [Research in Gerontological Nursing, 16(1), 5-13.].

Working Dynamics of Licensed Nurses and Nurse Aides in Nursing Homes: A Scoping Review.

Collaboration between licensed nurses (LNs) and nurse aides (NAs) is critical in the provision of quality care for residents living in nursing homes (NHs). The current scoping review explores how working dynamics between LNs and NAs in the NH setting are researched and described in the literature. Thirty-five articles were identified and reviewed that address the LN/NA relationship in the context of (a) the LN role as a supervisor and leader; (b) variation in structure; (c) expanding, understanding, and supporting staff roles; and (d) communication. We found that the LN/NA relationship has been primarily explored through the LN lens and often studied in the context of role expansion and revision associated with new models of care. Our contribution to the literature includes the following main points: efforts to improve LN/NA collaboration may be hindered without substantial structural change; collaboration may be limited within the hierarchal LN/NA relationship; LNs and NAs in NHs need greater support, recognition, and empowerment; and NAs require a representative voice. [Journal of Gerontological Nursing, 48(5), 27-34.].

Collaboration Between Licensed Nurses and Certified Nurse Aides in the Nursing Home: A Mixed Methods Study.

The current mixed methods study explored how nursing team collaboration is perceived and experienced in four nursing homes (NHs) in the western United States. Licensed nurses (LNs) and certified nurse aides (CNAs) completed two survey tools to assess their perception of collaboration and team-work in their current work environment. LNs and CNAs were paired and interviewed individually and as a caregiving pair to explore the lived experience of collaboration in NH residents' care. Quantitative survey results were analyzed, and participants reported a collaborative working environment with equally strong ratings in the following categories: partnership, cooperation, and coordination; they agreed with statements reflective of teamwork, including team structure, leadership, situation monitoring, mutual support, and communication. No significant differences were found between LN and CNA responses or between team members in any of the four participating facilities. Qualitative survey data were analyzed using a thematic analysis approach. Findings revealed five primary themes, including essential elements in successful team collaboration-perspective, coworker connection, communication, mutual support, and "it makes a difference"-and ways teamwork and collaboration impact resident care. These findings provide rich insights into successful LN/CNA collaboration for academic and clinical LN and CNA educators. [Research in Gerontological Nursing, 15(1), 16-26.].

Assisted Living: Optimal Person-Environment Fit.

Assisted living (AL) is a well-established alternative to nursing homes, promoting autonomy and choice in a residential environment. This article examines the opportunities that AL affords for older adults and areas for further research to optimize the fit between resident needs and the AL environment. The model of person-environment fit provides an organizing framework for our commentary. The environment of AL emphasizes choice, independence, and privacy. The acuity of health care needs in AL residents has evolved since its inception. Unlike earlier residents, many today live with multiple chronic conditions and need for functional supports. Regulated by states, there is high variability in oversight, staffing, and resources available in AL. Families play an important role in supporting residents, yet expectations for their engagement may not be clear. Descriptive research abounds but there is a need for more sophisticated approaches to understanding how the AL environment can provide optimal supports for older adults, across all states and across income and racial/ethnic groups. There are several methodological challenges to AL research, including the high variability among AL settings and across states, the lack of common data elements, and difficulty accessing representative samples. With the popularity of AL as an option, it will be important to continue to examine how this environment can evolve to meet the changing needs of the resident population, while balancing the elements of autonomy and affordability. [Research in Gerontological Nursing, 14(1), 5-12.].

Assuring Quality in Nursing Homes: The Black Box of Administrative and Clinical Leadership-A Scoping Review.

BACKGROUND AND OBJECTIVES: Licensed nursing home administrators (NHA) and directors of nursing (DON) are responsible for nursing home quality and assuring optimal performance and job satisfaction/retention of their nursing home workforce. NHA/DON-focused studies have generated important foundational knowledge over the last three decades; yet, targeted research is needed to understand and apply the complexities of the black box of this top management team. This scoping review identifies, reviews, synthesizes, and maps the topical areas of research in NHA/DON positions in U.S. nursing homes. RESEARCH DESIGN AND METHODS: We conducted searches of 5 databases, yielding 3,479 records; screening/review yielded 88 unique records. We used thematic analysis to code the primary foci of the studies and the variables associated with the concepts of interest. RESULTS: Most papers (n = 40) focused on role characteristics, 23 examined approaches to management and leadership, 24 focused on perceptions about the role, and the remaining 12 examined role structure. The role-related themes linked to outcomes (n = 42), processes (n = 27), and structures (n = 30). DISCUSSION AND IMPLICATIONS: We highlight important gaps for future research and offer a call to action for research, policy, practice, and education collaborations to accelerate the rate of research and translate the findings into best practices for NHA/DON to lead and manage the nursing home workforce and build capacity to ensure person-centered, high-quality care. Based on foundational descriptive studies, it is time to use what is known to design and implement interventions that enhance the capacity of NHA/DON to improve the structures, processes, and outcomes of nursing homes.

A qualitative study exploring the perceptions and motivations of patients with heart failure who transitioned from non-adherence to adherence.

BACKGROUND: Management of heart failure (HF) involves complex self-care recommendations. Many patients have difficulty adhering to these recommendations, and mechanisms that support behavior change are poorly understood. OBJECTIVE: The objective of this study was to explore the perceptions and motivations of individuals with HF who became adherent to HF treatment recommendations after being non-adherent. METHODS: This was a qualitative descriptive study. Participants were recruited from cardiology clinics and completed a semi-structured interview on their experiences and motivations for self-care behavior change. Data was analyzed using thematic analysis. The sample size (n = 8) was sufficient to achieve saturation. RESULTS: Five themes were identified: experiencing mortality, optimism and hope, making connections between behavior and health, self-efficacy, and the role of the clinician. The temporal chronological sequence of these themes across participants varied. CONCLUSIONS: This study adds to our current understanding of HF self-care by suggesting mechanisms that may enhance existing self-care interventions, and demonstrating the important role of the clinician.

New Directions to Advance Family Caregiving Research.

This supplement describes the content, processes, and outcomes of the Research Priorities in Caregiving Summit convened by the Family Caregiving Institute (FCI) at the Betty Irene Moore School of Nursing at UC Davis in March 2018. As described in the editorial introduction and the supplement's four papers, the summit sought to integrate and cross-pollenate the already compendious work on family caregiving to describe ways forward in the field. Thought-provoking commissioned synthesizing papers on issues of heterogeneity and trajectories of caregiving and its cultural embeddedness and on the potential of technology to shape and enhance caregiving interventions set the stage for a highly disciplined, multistaged process that resulted in the drafting of a set of research themes and priorities that were later finalized by faculty at the FCI.

Understanding Contextual Differences in Residential LTC Provision for Cross-National Research: Identifying Internationally Relevant CDEs.

Long-term care (LTC) reflects a growing emphasis on person-centered care (PCC), with services oriented around individuals' needs and preferences. Addressing contextual and cultural differences across countries offers important insight into factors that facilitate or hinder application of PCC practices within and across countries. This article takes an international lens to consider country-specific contexts of LTC, describing preliminary steps to develop common data elements that capture contextual differences across LTC settings globally. Through an iterative series of online, telephone, and in-person sessions, we engaged in in-depth discussions with 11 colleague experts in residential LTC and coauthors from six countries (China and Hong Kong, England, Sweden, Thailand, Trinidad and Tobago, and the United States). Our discussions yielded rich narrative describing a vast range in types of LTC settings, leading to our development of a working definition of residential LTC. Scope of services, funding, ownership, and regulations varied greatly across countries and across different residential LTC settings within countries. Moving forward, we recommend expanding our activities to countries that reflect different stages of residential LTC development. Our goal is to contribute to a larger initiative underway by the WE-THRIVE consortium to establish a global research measurement infrastructure that advances PCC internationally.

Nurse Managers' Experiences With Electronic Health Records in Quality Monitoring.

Little is known about how hospital-based nurse managers use electronic health records (EHR) to monitor nurse-sensitive quality measures, or about how they learn to do so. This article describes the role of nurse managers in quality monitoring, their experience in using the EHR to monitor nurse-sensitive quality measures, and their related training. A convenience sample of nurse managers and directors (n = 28) was recruited to participate in semistructured interviews. The resulting data were analyzed, using content analysis. This study revealed 3 components of the nurse manager's quality-monitoring role: monitoring documentation, monitoring practice, and performing investigations. Facilitators for accessing EHR information included ease of navigation, timeliness and accessibility of reports, and usefulness of EHR tools. Participants described a range of formal and informal approaches to learning how to access information for quality monitoring in general and for the EHR specifically. The findings provide direction for further exploration of the EHR structures and processes needed to support nurse managers' information needs and quality-monitoring training.

The health care aide position in nursing homes: A comparative survey of nurses' and aides' perceptions.

BACKGROUND: The health care aide position embodies one of the most basic paradoxes of long-term care for older adults: those who have the most contact and most intensive interaction with nursing-home residents are also those having the least training, authority, and status within the system. They therefore hold one of the keys to quality care in many settings, especially nursing homes. In the absence of agreement on the position's roles, responsibilities, and authority, it is important to examine how the position is perceived by the key members in the long-term-care framework. OBJECTIVES: The current study examined and compared health care aides' and nurses' perceptions of the position in nursing-home settings in Israel, using a standardized tool developed for this inquiry. The comparison accounted for potential intervening factors that may help better understand the job requirements and boundaries. DESIGN: A comparative survey design. SETTINGS: 30 nursing homes (of at least 20 beds) in northern Israel. PARTICIPANTS: We used convenience sampling to recruit 369 health care aides and 261 nurses (a total of 630 participants). METHODS: The main instrument of data collection was specially designed and validated for this study. It was based on a qualitative study that defined basic content units representing tasks importance, knowledge, and personal characteristics for the job. RESULTS: Participants found it difficult to prioritize the job components or to differentiate between core tasks and characteristics and the secondary aspects of their job. General care, profession-specific knowledge, and emotional abilities were endorsed the most by participants. Cleaning, communication, and safety were ranked lower (although rankings were still considerably high). However, previous experience as a health care aide undermined incumbents' perceptions of their own responsibilities and professionalism. Incumbent health care aides rated most factors higher than nurses did, with the exception of the importance of communication. CONCLUSION: Our results may help decision makers understand the complexity around the health care aide position, manage and develop it more effectively while setting standards (training and certification, performance appraisal, and more) for professionalization processes and better defining the division of nursing work between health care aides and nurses.

Toward Common Data Elements for International Research in Long-term Care Homes: Advancing Person-Centered Care.

To support person-centered, residential long-term care internationally, a consortium of researchers in medicine, nursing, behavioral, and social sciences from 21 geographically and economically diverse countries have launched the WE-THRIVE consortium to develop a common data infrastructure. WE-THRIVE aims to identify measurement domains that are internationally relevant, including in low-, middle-, and high-income countries, prioritize concepts to operationalize domains, and specify a set of data elements to measure concepts that can be used across studies for data sharing and comparisons. This article reports findings from consortium meetings at the 2016 meeting of the Gerontological Society of America and the 2017 meeting of the International Association of Gerontology and Geriatrics, to identify domains and prioritize concepts, following best practices to identify common data elements (CDEs) that were developed through the US National Institutes of Health/National Institute of Nursing Research's CDEs initiative. Four domains were identified, including organizational context, workforce and staffing, person-centered care, and care outcomes. Using a nominal group process, WE-THRIVE prioritized 21 concepts across the 4 domains. Several concepts showed similarity to existing measurement structures, whereas others differed. Conceptual similarity (convergence; eg, concepts in the care outcomes domain of functional level and harm-free care) provides further support of the critical foundational work in LTC measurement endorsed and implemented by regulatory bodies. Different concepts (divergence; eg, concepts in the person-centered care domain of knowing the person and what matters most to the person) highlights current gaps in measurement efforts and is consistent with WE-THRIVE's focus on supporting resilience and thriving for residents, family, and staff. In alignment with the World Health Organization's call for comparative measurement work for health systems change, WE-THRIVE's work to date highlights the benefits of engaging with diverse LTC researchers, including those in low-, middle-, and high-income countries, to develop a measurement infrastructure that integrates the aspirations of person-centered LTC.

Leadership in Nursing Homes: Directors of Nursing Aligning Practice With Regulations.

Nursing homes use team nursing, with minimal RN presence, leaving the majority of direct care to licensed practical/vocational nurses (LPNs/LVNs) and unlicensed assistive personnel (UAP), including medication aides. The current article describes challenges faced by nursing home directors of nursing (DONs) leading and managing a team nursing approach, including consideration of scope of practice, delegation and supervision regulations, and related policy implications. A secondary data analysis was performed of qualitative data from a study to develop and test DON guidelines for delegation in nursing home practice. A convenience sample (N = 29) of current or previous DONs and other nursing home leaders with knowledge and expertise in the DON role participated in in-depth, guided interviews. The findings highlight a core concern to nursing licensure policy and regulation: knowledge and practice gaps related to scope of practice and delegation and supervision among DONs, RNs, and LPNs/LVNs, as well as administrators, and the role of nursing leaders in supporting appropriate delegation practices. The findings offer directions for research and practice in addressing challenges in aligning team nursing practices with regulatory standards as well as the related gaps in knowledge among DONs, administrators, and nursing staff. [Journal of Gerontological Nursing, 44(6), 10-14.].

Quality Improvement in Nursing Homes: Alignment Among Leaders Across the Organizational Chart.

Background and Objectives: This article describes nursing home (NH) leaders' involvement in quality improvement (QI) decisions, with an emphasis on the concept of alignment in QI decisions across leaders. Research Design and Methods: We used a qualitative approach and semistructured interviews to collect data from a convenience sample of 39 NH leaders, including corporate/executive-level leaders and facility-level leaders. Thematic analysis was used to inductively capture key patterns in data. Results: Variations in alignment emerged as a major theme to describe the interface and interaction among facility- and corporate/executive-level leaders around QI decision making and implementation of QI decisions. For this study, alignment refers to the extent of shared understanding, beliefs, motivations, and implied or explicit agreement among leaders in regards to: (a) goals, values, priorities, and expectations for quality or QI (and/or applicable resources); and (b) expectations for leaders to carry out QI decisions made by other leaders. Discussion and Implications: This study offers new insights into the complexities associated with leadership alignment toward improving NH quality. The findings provide a glimpse into leaders' involvement in QI based on their position on the facility's organizational chart and extend our understanding of the centrality of the concept of alignment in promoting QI. These findings may inform future research on facility- and corporate/executive-level leader interactions and how these interactions impact quality outcomes.

Nursing Home Administrator Quality Improvement Self-Efficacy Scale.

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

Interprofessional Huddle: One Children's Hospital's Approach to Improving Patient Flow.

Admitting pediatric patients promptly to the appropriate unit where they can receive specialty care is of critical importance to safe, quality care. A daily morning huddle was implemented at one children's hospital as a quality improvement project. The aim of this project was to improve patient flow throughout the children's hospital by improving interprofessional and interdepartmental communication and collaboration. This article reports on changes in patient flow before and after implementation of the daily huddle, as measured by pediatric emergency department (ED) boarding times. This retrospective, descriptive study was conducted at a regional children's hospital within an academic hospital. Data were collected from the electronic medical record over two separate time periods coinciding with pre/post-huddle implementation. Non-random, purposive sampling was used, resulting in a prehuddle sample (n = 450) and post-huddle sample (n = 329). Times were significantly shorter after huddle implementation compared to pre-huddle (p < 0.001) from admission orders in the ED to transfer to the PICU or pediatric ward. The median time decreased from 3.0 to 2.6 hours post-huddle implementation. These findings suggest huddles as one potential factor in the formula to improve patient flow from the ED by enhancing interprofessional and interdepartmental collaboration and communication. Findings from this study are of vital importance to pediatric patients, nurses, and physicians. Promptly admitting patients from the ED to the appropriate unit where they can receive needed specialty care that potentially improves the quality and safety of patient care is paramount. Further research is needed to determine what format and contexts the huddle can be utilized to facilitate efficient patient flow and improve patient outcomes.

Evaluation of a peer mentoring program for early career gerontological nursing faculty and its potential for application to other fields in nursing and health sciences.

BACKGROUND: As the retirement rate of senior nursing faculty increases, the need to implement new models for providing mentorship to early career academics will become key to developing and maintaining an experienced faculty. PURPOSE: This evaluation of a peer mentorship program for predoctoral and postdoctoral gerontological nurses examined its efficacy, utility, and potential for improvement. METHODS: A web-based survey was developed, implemented, and completed by 22 mentees and 17 mentors (71% and 61% response rates, respectively) as part of the evaluation. DISCUSSION: The peer mentorship program was found to be valuable by both mentors (64.7%) and mentees (72.7%) in helping mentees further develop their careers and networks and providing mentors with supported mentorship experience. CONCLUSION: The peer mentorship program could serve as a model for other professional organizations, academic institutions, and consortiums to enhance and extend the formal vertical mentorship provided to early academic career individuals.

Evaluating psychiatric nursing competencies applied to emergency settings: A pilot role delineation study.

BACKGROUND: Despite increasing emergency department (ED) use for psychiatric emergencies, limited evidence exists to clearly identify the competencies necessary of emergency nurses to care for this population. PURPOSES: 1. To define the specialized skill and knowledge of emergency nurses by examining the frequency with which recommended psychiatric nursing competencies are performed in the ED setting. 2. To assess emergency nurses' rankings of importance and self-efficacy related to recommended psychiatric nursing competencies in order to explore their relevance to emergency nursing. METHODS: Emergency nurses (n = 75) completed a survey ranking the frequency, importance and self-efficacy of 15 psychiatric nursing competencies. Data analysis revealed competency relevance and regression analysis demonstrated factors that may contribute to self-efficacy. RESULTS: Nurses reported performing psychiatric competencies frequently (mean scores of 0.64 to 3.04). Importance rankings were highest (mean scores of 1.81 to 3.67). Self-efficacy mean scores ranged from 0.89 to 3.47. Frequency and importance of activities predicted higher self-efficacy scores. Younger age and <5 years experience had negative impacts on self-efficacy scores. IMPLICATIONS: Emergency nurses perform psychiatric competencies often, and existing competencies appear applicable. As frequency and importance of competencies influence self-efficacy, practice and interventions to underscore the importance of competencies may improve self-efficacy. Younger and less experienced nurses might require more support.

Recommendations From the International Consortium on Professional Nursing Practice in Long-Term Care Homes.

In response to the International Association of Gerontology and Geriatrics' global agenda for clinical research and quality of care in long-term care homes (LTCHs), the International Consortium on Professional Nursing Practice in Long Term Care Homes (the Consortium) was formed to develop nursing leadership capacity and address the concerns regarding the current state of professional nursing practice in LTCHs. At its invitational, 2-day inaugural meeting, the Consortium brought together international nurse experts to explore the potential of registered nurses (RNs) who work as supervisors or charge nurses within the LTCHs and the value of their contribution in nursing homes, consider what RN competencies might be needed, discuss effective educational (curriculum and practice) experiences, health care policy, and human resources planning requirements, and to identify what sustainable nurse leadership strategies and models might enhance the effectiveness of RNs in improving resident, family, and staff outcomes. The Consortium made recommendations about the following priority issues for action: (1) define the competencies of RNs required to care for older adults in LTCHs; (2) create an LTCH environment in which the RN role is differentiated from other team members and RNs can practice to their full scope; and (3) prepare RN leaders to operate effectively in person-centered care LTCH environments. In addition to clear recommendations for practice, the Consortium identified several areas in which further research is needed. The Consortium advocated for a research agenda that emphasizes an international coordination of research efforts to explore similar issues, the pursuit of examining the impact of nursing and organizational models, and the showcasing of excellence in nursing practice in care homes, so that others might learn from what works. Several studies already under way are also described.

Development and implementation of a peer mentoring program for early career gerontological faculty.

PURPOSE: The Hartford Gerontological Nursing Leaders (HGNL) formerly known as the Building Academic Geriatric Nursing Capacity Initiative (BAGNC), in conjunction with the National Hartford Centers of Gerontological Nursing Excellence (NHCGNE), developed and executed a peer mentoring program beginning in 2011 to enhance both (a) the experience of newly selected scholars and fellows to the NHCGNE and (b) the ongoing professional development of HGNL members. The purpose of this article is to describe key strategies used to develop and execute the peer mentoring program and to present formative program evaluation. DESIGN: The program was launched in January 2011 with seven peer mentor and mentee matches. In June 2012, the peer mentoring committee solicited feedback on the development of the peer mentoring program and changes were made for the subsequent cohorts. FINDINGS: An additional 12 matches were made in the following 2 years (2012 and 2013), for a total of 31 matches to date. We have learned several key lessons from our three cohorts regarding how to structure, implement, and carefully evaluate a peer mentoring program. CONCLUSIONS: Informal evaluation of our peer mentoring program noted several challenges for both peer mentors and mentees. Having knowledge of and addressing those challenges may increase the overall quality and effectiveness of peer mentoring programs and, in turn, benefit academic nursing by strengthening the faculty workforce. CLINICAL RELEVANCE: Findings from development and implementation of a peer mentoring program for gerontological faculty could lead to new and adaptable programs in a variety of clinical and education settings.