Assessment of Nursing Staff Learning Needs Around Person-Centered Risk Management in Nursing Homes.

The purpose of the current study was to describe nursing home (NH) staff's perceived learning and practice competency needs to facilitate effective delivery of person-centered care (PCC) when older adult residents' care preferences involve perceived risks. This needs assessment included a survey of NH staff and leaders (N = 87) and two focus groups (FGs) (N = 14). Results indicated staff were most confident handling preferences related to medication refusal (mean item rating = 4.1) and least confident in preferences related to smoking (mean item rating = 2.4). Staff were challenged in denying residents' preferences (mean item rating = 3.6) and worried about risk outcomes for residents or themselves (71.6%), reporting lack of policy and procedures to support them (48.1%). Survey results were enriched by FG themes: Establishing Person-Centered Values, Navigating Risk, and Operational Characteristics. Together, this information informed the development of a practice protocol to improve nursing competence in situations involving negotiation of resident and/or NH risks in care delivery. [Journal of Gerontological Nursing, 49(2), 7-12.].

Nursing Leadership - Transforming the Work Environment in Nursing Homes.

The work environment is a modifiable construct associated with the quality of nursing home care. This article describes and explains variables known to be associated with the work environment of nurses in nursing homes, including the history and characteristics of nursing homes; the nature of nursing work; the nursing skill mix, and care delivery. Nursing leadership has the potential to transform the nursing home work environment and improve quality of care through education, research, advocacy, and implementation of evidence-based practices.

A Call to the CMS: Mandate Adequate Professional Nurse Staffing in Nursing Homes.

Editor's note: This article is by 22 nursing gerontology experts who are all advocates of nursing home reform. They are listed at the end of this article.

Nursing surveillance and immediate jeopardy in Veteran Health Administration community living centers unannounced survey program 2018 to 2019.

BACKGROUND: The VA Community Living Center (CLC) Unannounced Survey Program aims to assess standards of care set by the government to protect residents. PURPOSE: To describe patterns of practice failures in nursing surveillance causing or having potential to cause immediate jeopardy, as defined by the Centers for Medicare and Medicaid Services. METHODS: Using CLC survey data consisting of 200 statements of deficiency (SODs) for 2018 to 2019, we collected a SOD sample (n = 20) of immediate jeopardy events. They were described using descriptive statistics and discourse content analysis. FINDINGS: We identified clinical events, their duration, work shift, and nursing skill mix for each SOD. Most to least common themes about failures in nursing surveillance were acquisition/transfer of information; decision-making; and early recognition of problems. DISCUSSION: Our analysis of nursing surveillance failures in CLC immediate jeopardy SODs provides insight into opportunities for registered nurses and the nursing skill mix to reduce avoidable harms.

Using the Observational Teamwork Assessment in Surgery Instrument to Measure RN Teamwork During Cardiac Surgery: Lessons Learned.

BACKGROUND: Surgical teams aspire to be safe and avoid preventable deaths. A lack of teamwork has been associated with safety failures, including adverse events and errors. PURPOSE: The purpose of the pilot study was to: (1) modify the Observational Teamwork Assessment in Surgery (OTAS) and the original data collection method to measure registered nurse (RN) teamwork during the intraoperative phase of 5 open heart surgical procedures and (2) recommend strategies to further test the reliability and validity of the modified OTAS. METHODS: This was a pilot study of the OTAS using direct observation. RESULTS: Although characterized as psychometrically rigorous in prior systematic reviews, using the OTAS to measure RN teamwork in the intraoperative phase of cardiac surgery revealed deficits in its content validity and reliability. The OTAS and its original data collection method were modified. CONCLUSION: Recommendations for further use of the modified OTAS to increase its reliability and validity are given.

Appropriate Nurse Staffing Levels for U.S. Nursing Homes.

US nursing homes are required to have sufficient nursing staff with the appropriate competencies to assure resident safety and attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident. Minimum nurse staffing levels have been identified in research studies and recommended by experts. Beyond the minimum levels, nursing homes must take into account the resident acuity to assure they have adequate staffing levels to meet the needs of residents. This paper presents a guide for determining whether a nursing home has adequate and appropriate nurse staffing. We propose five basic steps to: (1) determine the collective resident acuity and care needs, (2) determine the actual nurse staffing levels, (3) identify appropriate nurse staffing levels to meet residents care needs, (4) examine evidence regarding the adequacy of staffing, and (5) identify gaps between the actual staffing and the appropriate nursing staffing levels based on resident acuity. Data sources and specific methodologies are analyzed, compared, and recommended. The goal is to assist nursing home nurses and administrators to ensure adequate nursing home staffing levels that protect resident health, safety, and well-being.

Examining the Beliefs of Skilled Nursing Facility Directors of Nursing Regarding BSN Completion and the Impact of Nurse Leader Education on Patient Outcomes.

Research suggests that acute care patients cared for by baccalaureate-educated nurses have better outcomes. Directors of nursing (DONs) in skilled nursing facilities (SNFs) have lower rates of baccalaureate attainment than acute care nurses for unclear reasons. To understand the interest in advancing education, researchers surveyed SNF DONs in Connecticut to examine their beliefs about academic advancement and the impact of DON education on resident outcomes. Nearly 70% of participants with diplomas and associate degrees lacked interest in degree advancement and did not believe a baccalaureate degree is necessary for DONs or that DON level of education impacts resident outcomes. Alternatives to degree completion may include interventions to provide SNF DONs with skills for improving resident outcomes.

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.

Virtual Breakthrough Series, Part 1: Preventing Catheter-Associated Urinary Tract Infection and Hospital-Acquired Pressure Ulcers in the Veterans Health Administration.

BACKGROUND: In 2014 the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) implemented a Virtual Breakthrough Series (VBTS) collaborative to help VHA facilities prevent hospital-acquired conditions: catheter-associated urinary tract infection (CAUTI) and hospital-acquired pressure ulcers (HAPUs). METHODS: During the prework phase, participating facilities assembled a multidisciplinary team, assessed their current system for CAUTI or HAPU prevention, and examined baseline data to set improvement aims. The action phase consisted of educational conference calls, coaching, and monthly team reports. Learning was conducted via phone, web-based options, and e-mail. The CAUTI bundle focused on four key principles: (1) avoidance of indwelling urinary catheters, (2) proper insertion technique, (3) proper catheter maintenance, and (4) timely removal of the indwelling catheter. The HAPU bundle focused on assessment and inspection, pressure-relieving surfaces, turning and repositioning, incontinence management, and nutrition/hydration assessment and intervention. RESULTS: For the 18 participating units, the mean aggregated CAUTI rate decreased from 2.37 during the prework phase to 1.06 per 1,000 catheter-days during the action (implementation) phase (p < 0.001); the rate did not change for CAUTI nonparticipating sites. HAPU data were available only for 21 of the 31 participating units, whose mean aggregated HAPU rate decreased from 1.80 to 0.99 from prework to continuous improvement (p < 0.001). Staff education and documentation improvement were the most frequently implemented changes. CONCLUSION: This project helped improve CAUTI and HAPU rates in the VHA and presents a promising model for implementing a virtual model for improvement.

The Relationship Between Registered Nurses and Nursing Home Quality: An Integrative Review (2008-2014).

Nursing home care is expensive; second only to acute hospital care for inpatient Medicare costs. The increased focus on costs of care accrued by Medicare beneficiaries in nursing homes presents a valuable opportunity for registered nurses (RNs) to further demonstrate quantitatively the value they add to the capacity of the nursing home nursing skill mix to provide cost-effective and efficient quality care. Most of the studies included in this review consistently reported that higher RN staffing and higher ratios of RNs in the nursing skill mix are related to better NH quality. Concerns about the costs of employing more highly skilled RNs and directors of nursing that have the potential to positively influence members of the nursing skill mix will continue to influence nursing home industry hiring practices. For both the advancement of nursing as an applied science and the benefit of society at large, nursing researchers are challenged to better demonstrate how the increased presence of a RN on each shift has the potential to enhance the cost effectiveness, efficiency, and quality of nursing homes.

Comprehensive Care Plan Development Using Resident Assessment Instrument Framework: Past, Present, and Future Practices.

Development of the comprehensive care plan (CCP) is a requirement for nursing homes participating in the federal Medicare and Medicaid programs, referred to as skilled nursing facilities. The plan must be developed within the context of the comprehensive interdisciplinary assessment framework-the Resident Assessment Instrument (RAI). Consistent compliance with this requirement has been difficult to achieve. To improve the quality of CCP development within this framework, an increased understanding of complex factors contributing to inconsistent compliance is required. In this commentary, we examine the history of the comprehensive care plan; its development within the RAI framework; linkages between the RAI and registered nurse staffing; empirical evidence of the CCP's efficacy; and the limitations of extant standards of practices in CCP development. Because of the registered nurse's educational preparation, professional practice standards, and licensure obligations, the essential contributions of professional nurses in CCP development are emphasized. Recommendations for evidence-based micro and macro level practice changes with the potential to improve the quality of CCP development and regulatory compliance are presented. Suggestions for future research are given.

Pressure ulcer prevention in nursing homes: nurse descriptions of individual and organization level factors.

Sustaining pressure ulcer prevention (PUP) in nursing homes has been difficult to achieve. Implementation science researchers suggest that identification of individual staff and organizational factors influencing current practices is essential to the development of an effective and customized plan to implement practice changes in a specific setting. A mixed methods approach was used to describe nurses' perceptions of individual and organization-level factors influencing performance of PUP in two Veterans Health Administration (VHA) nursing homes prior to implementation of a national VHA initiative on Hospital Acquired Pressure Ulcers (HAPUs). Individual interviews of 16 nursing staff were conducted. Individual factors influencing practice were a personal sense of responsibility to Veterans and belief in the effectiveness and importance of preventive measures. Organizational factors were existence of cooperative practices between nursing assistants and licensed nurses in assessing risk; teamwork, communication, and a commitment to Veterans' well-being. Integration and reinforcement of such factors in the development and maintenance of customized plans of PUP initiatives is recommended.

Quality assurance and performance improvement in nursing homes: using evidence-based protocols to observe nursing care processes in real time.

The Quality Assurance and Performance Improvement Initiative, a component of the Affordable Care Act (2010), is a new approach to quality improvement for US nursing homes. The article describes components of the Quality Assurance and Performance Improvement Initiative, the unique contributions of registered nurses to its implementation, and data collection strategies using direct observation and evidence-based measures and protocols in a Quality Assurance and Performance Improvement program.

Supporting and promoting personhood in long term care settings: contextual factors.

The need for personhood-focused long-term care (LTC) is well-documented. A myriad of sociocultural, political, nursing/professional and organisational contexts facilitate or hinder registered nurses (RNs)' capacity to ensure personhood-focused LTC. Complexities derive from the countless interrelated aspects of these contexts, blurring clear distinctions of causality, responsibility and accountability. Context-related complexities were highlighted at a recent international conference attended by invited experts in LTC leadership from six countries (Canada, USA, England, Northern Ireland, New Zealand and Sweden). The group was convened to explore the value and contributions of RNs in LTC (McGilton, , International Journal of Older People Nursing 7, 282). The purpose of this paper is to expand the discussion of personhood-focused care beyond RNs, to contexts that influence the RN's capacity to ensure personhood-focused practices are embedded in LTC settings. Consistent with key topics covered at the international conference, we selected four major contexts for discussion in this paper: (i) sociocultural, (ii) public policy/financing/regulation, (iii) nursing/professional and (iv) organisational. For each context, we provide a brief description, literature and examples from a few countries attending the conference, potential impact on personhood-focused practices and RN strategies to facilitate personhood-focused care. The knowledge gained from attending to the influence of contextual factors on the RN's role in facilitating personhood-focused practices provides critical insights and directions for interventions aimed to maximise RN role effectiveness in LTC. In practice, understanding linkages between the various contexts offers indispensable insight for LTC nurse leaders charged with managing day-to-day operations and leading quality improvement initiatives that promote personhood-focused practices.

Observing how RNs use clinical time in a nursing home: a pilot study.

Registered nurses (RNs) working in nursing homes (NHs) are a scarce professional resource. Their responsibilities include direct (e.g., assessment, physical care, and medication administration) and indirect care (e.g., documentation, supervision, and other activities performed away from the resident to manage their care environment). The purpose of the study was to describe the direct and indirect care distribution of RNs working day shift in an NH. All RN care was observed, although RN care associated with pressure ulcer prevention as a clinical outcome was highlighted. Work sampling was conducted using a personal data assistant-based RN Observation Measure. RNs spent 59% of their time on indirect care. Little direct care could be linked with specific clinical categories relevant to pressure ulcer prevention. RNs are challenged to use RN clinical time more strategically.

Promoting Excellence in End-of-Life Care: lessons learned from a cohort of nursing home residents with advanced Huntington disease.

Huntington disease (HD) is a genetic neurodegenerative disorder that progresses over decades and is ultimately terminal. As HD advances, patients are frequently placed in institutional care settings, including nursing homes and hospices where family, nursing staff, and interdisciplinary team members are challenged to help patients live to their highest potential and die with dignity. Edgemoor, a distinct part of the San Diego County Psychiatric Hospital, is a regional referral facility for patients with HD. Over the past 8 years, we have cared for 53 patients with advanced HD and describe our experiences by presenting their demographic characteristics and the lessons we have learned in caring for them. Ultimately, we found that the Robert Wood Johnson Foundation's Promoting Excellence in End-of-Life Care Initiative provided a meaningful framework for setting clinical priorities. This framework is used to summarize the clinical lessons that nursing staff and interdisciplinary team members learned about caring well for institutionalized individuals with advanced HD.

The pivotal role of the director of nursing in nursing homes.

The impending wave of aging boomers heightens long-standing concerns for the quality and cost of nursing home care. As industry and policy leaders continue efforts to remedy substandard nursing home care delivery practices, development of a well-prepared and adequately supported workforce of directors of nursing (DONs) is essential to ensuring the industry's readiness for the aging wave population. Directors of nursing are in pivotal positions to influence nursing home quality and costs; however, research demonstrating the extent of this influence-actual and potential-is lacking, and industry leaders have collectively failed to address the current or future capacity of this workforce. A long history of inattention to the DON position, coupled with low expectations for the competencies and requisite educational preparation, has potentially compromised the capacity of DONs to promote and sustain high-quality, cost-effective nursing home care. The purpose of this article is to provide a comprehensive overview and discussion of the current and potential capacity of DONs to lead the delivery of high-quality, cost-effective nursing home care from industry, educational and professional development, healthcare policy, and organizational contexts. Proposed strategies and recommendations to enhance and promote the future capacity of DONs are also presented.

Nursing staff descriptions of clinical supervision and management inVeterans Affairs-affiliated nursing homes.

Forty nursing staff from 2 urban VA-affiliated nursing homes participated in separate focus groups for certified nursing assistants, licensed vocational nurses, and registered nurses. Staff described their experiences with nursing supervisory and managerial staff work behaviors related to 5 common clinical practices, including incontinence, mobility, nutrition, pain, and pressure ulcer management. Themes associated with these behaviors were identified using content analysis. Implications for nurses in supervisory, managerial, and leadership roles in nursing homes and other clinical settings are presented.