Federal requirements for nursing homes to include certified nursing assistants in resident care planning and interdisciplinary teams: A policy analysis.

Starting in 2016, Centers for Medicare and Medicaid Services implemented the first phase of a 3-year multi-phase plan revising the manner in which nursing homes are regulated. In this revision, attention was placed on the importance of certified nursing assistants (CNAs) to resident care and the need to empower these frontline workers. Phase II mandates that CNAs be included as members of the nursing home interdisciplinary team that develops care plans for the resident that are person-centered and comprehensive and reviews and revises these care plans after each resident assessment. While these efforts are laudable, there are no direct guidelines for how to integrate CNAs in the interdisciplinary team. We recommend the inclusion of direct guidelines, in which this policy revision clarifies the expected contributions from CNAs, their responsibilities, their role as members of the interdisciplinary team, and the expected patterns of communication between CNAs and other members of the interdisciplinary team.

Uncovering the Disconnect Between Nursing Workforce Policy Intentions, Implementation, and Outcomes: Lessons Learned From the Addition of a Nursing Assistant Role.

The use of nursing assistants has increased across health systems in the past 20 years, to alleviate licensed nurses' workload and to meet rising health care demands at lower costs. Evidence suggests that, when used as a substitute for licensed nurses, assistants are associated with poorer patient and nurse outcomes. Our multimethods study evaluated the impact of a policy to add nursing assistants to existing nurse staffing in Western Australia's public hospitals, on a range of outcomes. In this article, we draw the metainferences from previously published quantitative data and unpublished qualitative interview data. A longitudinal analysis of patient records found significantly higher rates adverse patient outcomes on wards that introduced nursing assistants compared with wards that did not. These findings are explained with ward-level data that show nursing assistants were added to wards with preexisting workload and staffing problems and that those problems persisted despite the additional resources. There were also problems integrating assistants into the nursing team, due to ad hoc role assignments and variability in assistants' knowledge and skills. The disconnect between policy intention and outcomes reflects a top-down approach to role implementation where assistants were presented as a solution to nurses' workload problems, without an understanding of the causes of those problems. We conclude that policy makers and managers must better understand individual care environments to ensure any new roles are properly tailored to patient and staff needs. Further, standardized training and accreditation for nursing assistant roles would reduce the supervisory burden on licensed nurses.

Intersecting Policy Contexts of Employment-Related Geographical Mobility of Healthcare Workers: The Case of Nova Scotia, Canada.

Mobility and movement is an increasingly important part of work for many, however, Employment-Related Geographical Mobility (ERGM), defined as the extended movement of workers between places of permanent residence and employment, is relatively understudied among healthcare workers. It is critical to understand the policies that affect ERGM, and how they impact mobile healthcare workers. We outline four key intersecting policy contexts related to the ERGM of healthcare workers, focusing on the mobility of Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Continuing Care Assistants (CCAs) in Nova Scotia: international labour mobility and migration; interprovincial labour mobility; provincial credential recognition; and, workplace and occupational health and safety.

Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis.

BACKGROUND: In many low- and middle-income countries women are encouraged to give birth in clinics and hospitals so that they can receive care from skilled birth attendants. A skilled birth attendant (SBA) is a health worker such as a midwife, doctor, or nurse who is trained to manage normal pregnancy and childbirth. (S)he is also trained to identify, manage, and refer any health problems that arise for mother and baby. The skills, attitudes and behaviour of SBAs, and the extent to which they work in an enabling working environment, impact on the quality of care provided. If any of these factors are missing, mothers and babies are likely to receive suboptimal care. OBJECTIVES: To explore the views, experiences, and behaviours of skilled birth attendants and those who support them; to identify factors that influence the delivery of intrapartum and postnatal care in low- and middle-income countries; and to explore the extent to which these factors were reflected in intervention studies. SEARCH METHODS: Our search strategies specified key and free text terms related to the perinatal period, and the health provider, and included methodological filters for qualitative evidence syntheses and for low- and middle-income countries. We searched MEDLINE, OvidSP (searched 21 November 2016), Embase, OvidSP (searched 28 November 2016), PsycINFO, OvidSP (searched 30 November 2016), POPLINE, K4Health (searched 30 November 2016), CINAHL, EBSCOhost (searched 30 November 2016), ProQuest Dissertations and Theses (searched 15 August 2013), Web of Science (searched 1 December 2016), World Health Organization Reproductive Health Library (searched 16 August 2013), and World Health Organization Global Health Library for WHO databases (searched 1 December 2016). SELECTION CRITERIA: We included qualitative studies that focused on the views, experiences, and behaviours of SBAs and those who work with them as part of the team. We included studies from all levels of health care in low- and middle-income countries. DATA COLLECTION AND ANALYSIS: One review author extracted data and assessed study quality, and another review author checked the data. We synthesised data using the best fit framework synthesis approach and assessed confidence in the evidence using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether the factors identified by health workers in our synthesis as important for providing maternity care were reflected in the interventions evaluated in the studies in a related intervention review. MAIN RESULTS: We included 31 studies that explored the views and experiences of different types of SBAs, including doctors, midwives, nurses, auxiliary nurses and their managers. The included studies took place in Africa, Asia, and Latin America.Our synthesis pointed to a number of factors affecting SBAs' provision of quality care. The following factors were based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they were not always given sufficient training during their education or after they had begun clinical work. Also, inadequate staffing of facilities could increase the workloads of skilled birth attendants, make it difficult to provide supervision and result in mothers being offered poorer care. In addition, SBAs did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues were seen to increase stress and to negatively affect family life. Some SBAs also felt that managers lacked capacity and skills, and felt unsupported when their workplace concerns were not addressed.Possible causes of staff shortages in facilities included problems with hiring and assigning health workers to facilities where they were needed; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of care; these included good-quality housing, allowances for extra work, paid vacations, continuing education, appropriate assessments of their work, and rewards.Skilled birth attendants' ability to provide quality care was also limited by a lack of equipment, supplies, and drugs; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce SBAs' morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for SBAs to refer women on to higher levels of care. In addition, women's negative perceptions of the health system could make them reluctant to accept referral.We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants' motivation, their decision-making abilities, and the quality of care. Skilled birth attendants' workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers. AUTHORS' CONCLUSIONS: Many factors influence the care that SBAs are able to provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork and of trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to all of these factors.

[The new methods to define the staffing requirements for doctors,nurses and nurses aides: an example of their implementation in an Italian hospital]. / Le nuove metodologie di valutazione del fabbisognodel personale infermieristico, medico e di supporto: un esempio di applicazione.

. The new methods to define the staffing requirements for doctors, nurses and nurses aides: an example of their implementation in an Italian hospital. The Italian government, after the transposition of European Union legislation on working hours, made a declaration of commitment to increase the number of staff of the National Health Service (NHS). The method for assessing the staffing needs innovates the old one that dated back a few decades. AIM: To implement the method proposed by the Ministry of Health to an Italian hospital and assess its impact on staffing and costs. METHODS: The model was implemented on all the wards, multiplying the minutes of care expected in 2016, dividing the result by 60 to obtain the hours of care, and further dividing by the number of yearly hours of work of a nurse (1418). Same was done for nurses aides. The minutes of care were related to mean weight of the Diagnosis Related Groups of the ward and the results obtained compared to the actual staffing of nurses and nurses aides. The costs of the differences were calculated. RESULTS: The implementation of the model produced an excess of 23 nurses and a scarcity of 95 nurses aides compared to the actual staffing, with an increase of the costs of € 1.828.562,00. CONCLUSIONS: The results obtained and the criticisms received so far show the need of major changes. The data from international studies that associate staffing and patients outcomes and the nurse/patient ratio are macro-indicators already available that may orient choices and investments on the health care professions.

The challenges of upskilling health care assistants in community nursing.

Community care is at the forefront of the National Health Service reforms. Role redistribution from registered nurses to health care assistants is growing. This paper examines the challenges of upskilling community health care assistants to undertake catheterisation for uncomplicated patients in the community. Social constructivist methods facilitated reflective practice. Challenges included fears around delegation, accountability and the responsibilities involved in supporting the development of health care assistants. Recommendations suggest that community health care assistants offer a valuable and much needed contribution to health care delivery and are enthusiastic to upskill in catheterisation. However, reluctance from community registered nurses around delegation delayed the process. Registered nurses will need to address these fears and engage in workforce planning to proactively influence role developments and safe practice. National guidance needs to be structured around clear pathways to support these valued participants in delivering health care.

Assessment of immigrant certified nursing assistants' communication when responding to standardized care challenges.

OBJECTIVE: Certified nursing assistants (CNAs) provide 80% of the hands-on care in US nursing homes; a significant portion of this work is performed by immigrants with limited English fluency. This study is designed to assess immigrant CNA's communication behavior in response to a series of virtual simulated care challenges. METHODS: A convenience sample of 31 immigrant CNAs verbally responded to 9 care challenges embedded in an interactive computer platform. The responses were coded with the Roter Interaction Analysis System (RIAS), CNA instructors rated response quality and spoken English was rated. RESULTS: CNA communication behaviors varied across care challenges and a broad repertoire of communication was used; 69% of response content was characterized as psychosocial. Communication elements (both instrumental and psychosocial) were significant predictors of response quality for 5 of 9 scenarios. Overall these variables explained between 13% and 36% of the adjusted variance in quality ratings. CONCLUSION: Immigrant CNAs responded to common care challenges using a variety of communication strategies despite fluency deficits. PRACTICE IMPLICATIONS: Virtual simulation-based observation is a feasible, acceptable and low cost method of communication assessment with implications for supervision, training and evaluation of a para-professional workforce.

Putting HCAs on the map.

The European Union is required to ensure human health is protected through its policies. The brief was to establish a pilot network and database of nurse educators and regulators to improve the qualifications of healthcare assistants (HCAs), with a particular emphasis on cross-border mobility.

Theoretical and practical knowledge of nursing professionals on indirect blood pressure measurement at a coronary care unit.

OBJECTIVE: To determine and to analyze the theoretical and practical knowledge of Nursing professionals on indirect blood pressure measurement. METHODS: This cross-sectional study included 31 professionals of a coronary care unit (86% of the Nursing staff in the unit). Of these, 38.7% of professionals were nurses and 61.3% nurse technicians. A validated questionnaire was used to theoretical evaluation and for practice assessment the auscultatory technique was applied in a simulation environment, under a non-participant observation. RESULTS: To the theoretical knowledge of the stages of preparation of patient and environment, 12.9% mentioned 5-minute of rest, 48.4% checked calibration, and 29.0% chose adequate cuff width. A total of 64.5% of professionals avoided rounding values, and 22.6% mentioned the 6-month deadline period for the equipment calibration. On average, in practice assessment, 65% of the steps were followed. Lacks in knowledge were primary concerning lack of checking the device calibration and stethoscope, measurement of arm circumference to choose the cuff size, and the record of arm used in blood pressure measurement. CONCLUSION: Knowledge was poor and had disparities between theory and practice with evidence of steps taken without proper awareness and lack of consideration of important knowledge during implementation of blood pressure measurement. Educational and operational interventions should be applied systematically with institutional involvement to ensure safe care with reliable values.

Theoretical and practical knowledge of Nursing professionals on indirect blood pressure measurement at a coronary care unit / Conhecimento teórico e prático dos profissionais de Enfermagem em unidade coronariana sobre a medida indireta da pressão arterial

Objective To determine and to analyze the theoretical and practical knowledge of Nursing professionals on indirect blood pressure measurement. Methods This cross-sectional study included 31 professionals of a coronary care unit (86% of the Nursing staff in the unit). Of these, 38.7% of professionals were nurses and 61.3% nurse technicians. A validated questionnaire was used to theoretical evaluation and for practice assessment the auscultatory technique was applied in a simulation environment, under a non-participant observation. Results To the theoretical knowledge of the stages of preparation of patient and environment, 12.9% mentioned 5-minute of rest, 48.4% checked calibration, and 29.0% chose adequate cuff width. A total of 64.5% of professionals avoided rounding values, and 22.6% mentioned the 6-month deadline period for the equipment calibration. On average, in practice assessment, 65% of the steps were followed. Lacks in knowledge were primary concerning lack of checking the device calibration and stethoscope, measurement of arm circumference to choose the cuff size, and the record of arm used in blood pressure measurement. Conclusion Knowledge was poor and had disparities between theory and practice with evidence of steps taken without proper awareness and lack of consideration of important knowledge during implementation of blood pressure measurement. Educational and operational interventions should be applied systematically with institutional involvement to ensure safe care with reliable values. .

Objetivo Determinar e analisar o conhecimento teórico e prático de profissionais de Enfermagem sobre a medida indireta da pressão arterial. Métodos Estudo descritivo, transversal, com profissionais de Enfermagem de uma unidade coronariana. Participaram do estudo 31 sujeitos (86% da população), sendo 38,7% enfermeiros e 61,3% técnicos em enfermagem. A avaliação teórica ocorreu por meio de questionário validado, e a prática, com técnica auscultatória, em simulação, sob observação não participativa. Resultados Sobre o conhecimento teórico do preparo do cliente e ambiente, 12,9% citaram repouso de 5 minutos, 48,4% conferiram calibração e 29,0% escolheram o manguito correto. Já 64,5% evitaram o arredondamento dos valores, e 22,6% citaram o prazo semestral para a calibração dos aparelhos. Na avaliação prática, em média, 65% das etapas foram cumpridas. Dentre as lacunas desse conhecimento, destacaram-se a ausência de checagem da calibração do aparelho e do estetoscópio, a medida da circunferência braquial para escolher o manguito, e o registro do braço usado na medida. Conclusão: O conhecimento foi insatisfatório, com discrepâncias entre a teoria e a prática, com indícios de etapas cumpridas sem a devida consciência, e conhecimentos importantes negligenciados na execução da medida da pressão arterial. Intervenções educativas e operacionais devem ser sistematicamente aplicadas, com o envolvimento institucional, para garantir segurança da assistência com valores fidedignos. .

Reduced postpartum hemorrhage after implementation of active management of the third stage of labor in rural Honduras.

OBJECTIVE: To assess outcomes after auxiliary nurses were trained and given resources to use active management of the third stage of labor (AMTSL) for all women giving birth in a low-resource, low-risk, rural, public birth center setting in northern rural Honduras. METHODS: Auxiliary nurses received training on estimation of blood loss before the preintervention phase of the study (July 2004 through April 2005) and AMTSL, including use of intramuscular oxytocin, and estimation of blood loss prior to the intervention phase (July 2007 through June 2008). Preintervention and intervention data on use of oxytocin, blood loss postpartum, hemorrhage rates, and management interventions were collected and compared. RESULTS: After nurses received training on AMTSL using intramuscular oxytocin, the use of intramuscular oxytocin during the third stage of labor increased from 63.8% to 96.5%. Postpartum hemorrhage rates decreased from 14.8% to 5.9% (P=0.001). Use of intrapartum oxytocin, which can have adverse effects, also increased: from 6.1% to 22.7% (P<0.001). CONCLUSION: Training auxiliary nurses to perform AMTSL using oxytocin in this birth center setting was effective in reducing the rate of postpartum hemorrhage; however, increased use of intrapartum oxytocin may be an unintended outcome of the increased accessibility of oxytocin.

Reassessing nurse aide job satisfaction in a Texas nursing home.

This article reports a study that replicates and extends Castle's 2007 study by examining factors related to satisfaction of nurse aides at Carillon House, a 120-bed nonprofit skilled nursing facility in Lubbock, Texas. The Nursing Home Nurse Aide Job Satisfaction Questionnaire was adapted to allow for the collection of qualitative responses and administered to the nursing staff. The results suggest that satisfaction among nurse aides is related to rewards, workload, and the team environment created among coworkers. These findings differ from what is generally found in the literature and may be related to the higher-than-average satisfaction rating of nurse aides at this facility. The study provides evidence that large-scale surveys may have ignored a stratified effect where higher satisfaction organizations have different driving forces than what has been demonstrated in the literature to date.

CNN code of conduct.

It is important that a CNN understands their employer's local policies, procedures and clinical protocols. To enable a CNN to practise, they must be appropriately trained, have clinical supervision and work in partnership with others. A CNN must maintain client confidentiality, and act accordingly with all partnership communications. A CNN has a duty of care to themselves, the clients, colleagues and the employer.

Should self-assessment methods be used to measure compliance with handwashing recommendations? A study carried out in a French university hospital.

BACKGROUND: Implementation of a hand hygiene promotion program in a large university hospital required that we find a suitable method to assess health care workers' (HCWs) hand hygiene practices. This study aims at comparing direct observation and self-assessment methods. METHODS: Hand hygiene practices of 206 HCWs (physicians, nurses, and nurse assistants) in 25 care units were directly observed by trained auditors for 1 day. A week later, 1050 HCWs filled out a self-assessment questionnaire on their compliance with handwashing indications (participation rate was 83%). RESULTS: Average global self-reported compliance rate (SRR) after patient care was similar to the observed rate (OBR) (74%). According to the type of care, differences between SRR and OBR were nonsignificant, except for change of infusion bag by nurses and nursing care by nurse assistants. Physicians and nurse assistants tended systematically to over evaluate their compliance, whereas nurses tended to under evaluate their compliance with hand hygiene recommendations. CONCLUSIONS: Mean compliance rates were higher than those reported in the literature but varied as a function of patient care activity and occupation of the HCW. A reinforced in-service educational program will be implemented that will target especially physicians and medical students. Self-assessment method, easy to use and inexpensive, gave encouraging results. The development of a broad-based, routine, self-assessment program is underway at Nantes University Hospital, but, before such a program can be implemented, reproducibility of these self-assessment indicators must be further confirmed.

The role and accountability of senior health care support workers in intensive care units.

BACKGROUND: Nurses have always looked to support their activities through the presence of unregistered co-workers. In the later part of the 20th century this workforce has evolved from a predominance of students to increasing use of variously prepared second level nurses, nursing assistants and Health Care Support Workers. METHOD: The study evaluated the development of 'advanced' support workers for intensive care settings, examining the views of the multi-disciplinary team, the support workers, and making observations of the work undertaken. Ethical approval was gained via a multi-centre committee. Individual interviews, focus groups and fieldwork provided rich qualitative data. It is this, and the views of support workers themselves on which we focus in this report. RESULTS: Senior support workers have a potentially important, but as yet insufficiently clear role to play. Key tasks such as taking arterial blood gas symbolise their rite of passage into the role. Expectations vary by locality and by person and there is great concern over accountability for work done. Delegation of work depends as much on experience as training and individuals are reluctant to delegate to staff they have not personally assessed and come to know as 'competent'. CONCLUSION: These workers should have clear and adequately remunerated career pathways open to them, in particular into nursing and allied health disciplines, and should probably be licensed to practice.