Staffing Levels and COVID-19 Infections and Deaths in Korean Nursing Homes.

The novel coronavirus disease 2019 (COVID-19) spread rapidly worldwide. Nursing home (NH) residents are the most vulnerable high-risk population to infection. Professional registered nurses' (RNs') infection control is irreplaceable. We used a secondary data analysis method using the government's senior citizen welfare department large data set about all NHs (N = 3,389) across Korea between January 20 and October 20, 2020. Bed size positively associated with the mortality rate (No. of COVID-19 resident deaths / No. of total residents) (p = .048). When the proportion of RNs to total nursing staff was higher, the infection rate was 0.626% lower (p = .049), the mortality rate was 0.088% lower (p = .076), the proportion of confirmed COVID-19 cases per resident out of the total number of NHs was 44.472% lower (p = .041), and the proportion of confirmed COVID-19 deaths per resident out of the total number of NHs was 6.456% lower (p = .055). This study highlighted nurse staffing criteria and suggests that increasing RNs in NHs will reduce infection and mortality rates during the COVID-19 pandemic. We strongly suggest NHs hire at least one RN per day to properly function, and a minimum of four RNs to provide a fully competent RN workforce in long-term care settings in Korean NHs.

Appropriate Nursing Home Nurse Hours per Resident Day in Korea: A Secondary Analysis of Longitudinal Data.

PURPOSE: To encourage the enactment of laws about mandatory nurse staffing in nursing homes, researchers should provide evidence of concrete nurse hours per resident day (HPRD). This article estimates optimal nurse staffing HPRD to achieve increased quality-of-care outcomes for nursing home residents. DESIGN: Secondary analysis of longitudinal data. METHODS: This study used secondary analysis of longitudinal nursing home survey data. Nurse staffing HPRD and quality-of-care survey data accrued from nursing homes operating under long-term-care insurance in Korea. The collected data include a total of six quarterly base measurements on nurse staffing HPRD and 15 quality indicators from 2014 to 2017. The proposed optimization model emerged to most appropriately combine nurse staffing HPRD to increase quality-of-care outcomes for nursing home residents by 3% to 8%. Optimal outcome measures were fixed as best outcomes and compiled from 15 nursing-sensitive quality indicators. FINDINGS: Constrained nonlinear optimization was used for analysis. A 12% increase in registered nurse (RN) HPRD (from 0.168 HPRD [10 min 5 s] to 0.177 [10 min 38 s]) aligned with a 3% improvement in quality-of-care outcomes. A 20% RN HPRD increase aligned with a commensurate 5% to 8% increase in compiled quality-of-care outcomes (from 0.168 HPRD [10 min 5 s] to 0.202 HPRD [12 min 6 s]) without increasing certified nurse aide HPRD. About a 30% RN HPRD increase aligned with a commensurate 5% to 8% increase in compiled quality-of-care outcomes (from 0.168 HPRD [10 min 5 s] to 0.218 HPRD [13 min 6 s]) without increasing certified nurse aide HPRD. CONCLUSIONS: It is urgent to institute mandatory nurse HPRD for nursing homes in Korea by law. This research provides evidence that increasing nursing HPRD improved residents' outcomes in nursing homes. CLINICAL RELEVANCE: Findings from the optimization model implied that stable care by RNs in nursing homes is a key factor in achieving acceptable quality of care for residents.

The effect of registered nurses on nursing home residents' outcomes, controlling for organizational and health care market factors.

Despite cumulative and integrative evidence of registered nurse (RN) staffing on nursing home residents' outcomes worldwide, few studies integrate the effects of residents' case mix, healthcare markets, and nurse staffing on psychotropic-medication use and weight loss in Korea. This article examined the relationship between nurse staffing and residents' quality-of-care outcomes, controlling for long-term healthcare market characteristics in Korea. Using a multilevel cross-sectional design, a disproportionate stratified random sampling was used. Of 87 nursing homes contacted, 60 agreed to participate. Weighted linear regression was used to test the hypotheses. RN hours per resident day (HPRD) had a statistically significant positive impact on reducing the number of residents with psychotropic medication (ß = - .331, p = .008). Greater RN HPRD positively marginally related to fewer residents with cognitive impairment (ß = - 0.201, p = .139). Higher turnover of RN staff related to decreased proportions of residents with weight loss (ß = - .331 p = .008). Policymakers should cautiously consider requiring mandatory nurse staffing in nursing homes in Korea, where it is still acceptable to have certified nurse aids as substitutes for RNs.

Why Do We Require Registered Nurses in Nursing Homes? Using Longitudinal Hierarchical Linear Modeling.

AIMS: To examine the relationship between nurse staffing and quality of care of nursing home residents, longitudinally. BACKGROUND: Mixed results abound on the relationship between nurse staffing and quality of care of residents in nursing homes. Cross-sectional designs may underpin bias because the relationship between staffing and quality emerges over time, with latent unobserved variables. To offset this limitation, I used a longitudinal design in this study. DESIGN: I used repeated quarterly survey methods. METHODS: I measured staffing information with a formula developed by the Centers for Medicare & Medicaid Services. Outcome variables were 15 quality indicators and the Korean National Health Insurance Service 2015 nursing home evaluation manual. RESULTS AND FINDINGS: As registered nurse hours per resident day increased by 1, the percentage of residents with depression decreased by 3.88%, and the prevalence of residents with nasogastric tubes increased by 1.17% in 3 months. Prevalence of residents with bed rest decreased by 5.72%, and residents with restraints decreased by 1.092%. More registered nurses and fewer certified nursing assistants or qualified care workers yielded a statistically significant negative influence on aggressive behavior, depression, weight loss, and bed rest. The higher turnover of total nursing staff related to more use of antidepressants. CONCLUSIONS: Results supported registered nurses' exclusive impact on resident outcomes. More longitudinal research is required to confirm the influence of nurses on nursing home residents' outcomes. CLINICAL RELEVANCE: This study supported about the contributions of increased input of Registered Nurses, additional to previous longitudinal studies. The nursing homes in Korea should have mandatory Registered Nurse placement for optimal quality of care. CLINICAL RELEVANCE: This study supported about the contributions of increased input of Registered Nurses, additional to previous longitudinal studies. The nursing homes in Korea should have mandatory Registered Nurse placement for optimal quality of care.

Nurse Staffing and Quality of Care of Nursing Home Residents in Korea.

PURPOSE: To investigate the relationship between nurse staffing and quality of care in nursing homes in Korea. METHODS: This study used a cross-sectional design to describe the relationship between nurse staffing and 15 quality-of-care outcomes. Independent variables were hours per resident day (HPRD), skill mix, and turnover of each nursing staff, developed with the definitions of the Centers for Medicare & Medicaid Services and the American Health Care Association. Dependent variables were prevalence of residents who experienced more than one fall in the recent 3 months, aggressive behaviors, depression, cognitive decline, pressure sores, incontinence, prescribed antibiotics because of urinary tract infection, weight loss, dehydration, tube feeding, bed rest, increased activities of daily living, decreased range of motion, use of antidepressants, and use of restraints. Outcome variables were quality indicators from the U.S. Centers for Medicare & Medicaid and 2013 nursing home evaluation manual by the Korean National Health Insurance Service. FINDINGS: The effects of registered nurse (RN) HPRD was supported in fall prevention, decreased tube feeding, decreased numbers of residents with deteriorated range of motion, and decreased aggressive behavior. Higher turnover of RNs related to more residents with dehydration, bed rest, and use of antipsychotic medication. CONCLUSIONS: Study results supported RNs' unique contribution to resident outcomes in comparison to alternative nurse staffing in fall prevention, decreased use of tube feeding, better range of motion for residents, and decreased aggressive behaviors in nursing homes in Korea. More research is required to confirm the effects of nurse staffing on residents' outcomes in Korea. CLINICAL RELEVANCE: We found consistency in the effects of RN staffing on resident outcomes acceptable. By assessing nurse staffing levels and compositions of nursing staffs, this study contributes to more effective long-term care insurance by reflecting on appropriate policies, and ultimately contributes to the stable settlement of the long-term care insurance system for elders.

Comparing the nurse staffing in Korean and U.S. nursing homes.

INTRODUCTION: The quality of nursing home care has been problematic in both the United States and South Korea; quality is limited to inadequate nurse staffing levels. This article addresses how South Korean nursing home education and training requirements, nurse staffing standards, and actual nurse staffing levels compare with those in the United States. METHODS: The study used secondary documents and data to compare the two countries. RESULTS: Korea has lower registered nurse and certified nursing assistant standards and actual staffing levels than the United States. In contrast, staffing standards and actual staffing levels for care workers who provide direct care to residents are higher in Korea than in the United States. CONCLUSIONS: Research is needed in Korea to establish an empirical basis for educational requirements, staffing standards, and staffing levels in nursing homes.

Doll therapy: an intervention for nursing home residents with dementia.

The use of dolls as a therapeutic intervention for nursing home residents with dementia is relatively new. The current article describes a research study implemented with nursing home residents in Korea to examine the effects of doll therapy on their mood, behavior, and social interactions. A one-group, pretest-posttest design was used to measure the impact of doll therapy on 51 residents with dementia. Linear regression demonstrated statistically significant differences in aggression, obsessive behaviors, wandering, negative verbalization, negative mood, and negative physical appearance after introduction of the doll therapy intervention. Interactions with other individuals also increased over time. Findings support the benefits of doll therapy for nursing home residents with dementia; however, further research is needed to provide more empirical evidence and explore ethical considerations in the use of doll therapy in this vulnerable population.

Identification of North American Nursing Diagnosis Association-Nursing Interventions Classification-Nursing Outcomes Classification of nursing home residents using on-time data by android smartphone application by registered nurses.

PURPOSE: We aimed to investigate the nursing process linkages formed by Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) according to the primary NANDA-I diagnoses by registered nurses (RNs), customized to nursing home (NH) residents in Korea, using a developed smartphone application for NH RNs. METHODS: This is a retrospective descriptive study. Applying quota sampling, a total of 51 NHs from all operating 686 NHs hiring RNs participated in this study. Data were collected from June 21 to July 30, 2022. Data on NANDA-I, NIC, NOC (NNN) of nurses applied to the NH residents were collected through a developed smartphone application. The application consists of general organization and residents' characteristics, NANDA-I, NIC, and NOC. RNs selected randomly up to 10 residents and NANDA-I with risk factors and related factors over the past 7 days, followed by all applied interventions out of 82 NIC. RNs then evaluated residents through 79 selected NOC. RESULTS: We found the frequently used NANDA-I diagnoses, Nursing Interventions Classifications and Nursing Outcomes and Classifications applied for NH residents by RNs and developed the top five NOC linkages used to build care plan. CONCLUSION: It is time to pursue high-level evidence and reply to the questions raised in NH practice using NNN with high technology. The outcomes for patients and nursing staff are improved by the continuity of care made possible by uniform language. IMPLICATIONS FOR NURSING PRACTICE: NNN linkages should be used to construct and utilize the coding system of electronic health records or electronic medical records in Korean long-term care facilities.

Relationship between nursing staffing and quality of life in nursing homes.

PURPOSE: To investigate the relationship between nurse staffing and quality of life in nursing homes. METHODS: This is a descriptive, correlational study. The independent variables were nursing staffing hours per resident day (HPRD), skill mix HPRD, and turnover rate of nursing staff. The data for the dependent variables were collected using the quality of life (QOL) section of minimum data set (MDS) version 3.0. Hierarchical linear models were used for data analysis. RESULTS: Few staffing variables were statistically associated with residents' QOL. More RN HPRD were associated with better comfort and enjoyment domains, more licensed practical nurses (LPN) HPRD were associated with better dignity, and more certified nurse assistant (CNA) HPRD were associated with better functional competence domains. In terms of skill mix, the unique contribution of more RNs (to less LPN or CNAs) was supported in the functional competence of residents. However, surprising results were that: (a) as the HPRD of RNs increased, the scores of meaningful activity and relationship decreased; and (b) the contribution of LPNs (more LPNs to less RNs) were supported in the autonomy and spiritual well-being domains. Interestingly, nursing staff turnover is positively correlated with some domains of QOL: (a) a higher score in the enjoyment domain with increased RN turnover; and (b) a higher score in privacy, relationship, and individuality domains with increased turnover of LPNs. CONCLUSION: This is a preliminary study to investigate the relationship between nursing staffing and QOL for nursing home residents. Further examination is needed to confirm the relationship and provide policy guidelines, including nurse staffing recommendations.

Heuristic smartphone usability evaluations of the mobile application NANDA, nursing interventions classification, and nursing outcomes classification customized for nursing home registered nurses.

PURPOSE: We aimed to evaluate the usability of a smartphone application consisting of standardized nursing language (SNL) using NANDA, Nursing Intervention Classification, and Nursing Outcome Classification for nursing home nurses. DATA SOURCES: Applying convenience sampling, a total of 14 experts and 15 real users were invited to test and evaluate the smartphone application independently. For the usability evaluation of the developed application, the Korean version of the Mobile Application Rating Scale for experts and Mobile Application Rating Scale: User Version developed by Stoyanov et al. were used. DATA SYNTHESIS: Both groups determined that the SNL application was quite informative about SNL and efficient function; however, the engagement was quite lower than other categories. CONCLUSIONS: Although SNLs were scientifically developed for several decades, the widely available technological application for registered nurses in different languages is urgently needed to improve quality of nursing care. IMPLICATIONS FOR NURSING PRACTICE: The identified problems and recommendations by users and experts using heuristic evaluation will be reflected in the application's final version to be used for research.

Factors Affecting COVID-19 Incidences and Deaths of Geriatric Hospital Patients in Korea.

The current retrospective study aimed to investigate the association between organizational factors and nursing staff in geriatric hospitals and coronavirus disease 2019 (COVID-19) incidences and deaths using secondary data from governments nationwide in Korea. We used data on the number of COVID-19-confirmed cases and deaths among older adults in geriatric hospitals and nursing staff levels in those hospitals. We found that when the RN level was higher than the sample mean, the number of COVID-19-confirmed cases by geriatric hospital was significantly lower (4.3%; p = 0.05) and the number of deaths by geriatric hospital was marginally significantly lower (1.4%; p = 0.05). This study presented the national description of geriatric hospitals during the COVID-19 pandemic in terms of organizational and nursing staff factors. Findings highlight the impact of nursing staff skill mix and number of geriatric hospitals during the COVID-19 pandemic in Korea. It is necessary to allocate a realistic designation of infection control staff and establish a clear standard so infection control activities in geriatric hospitals can proceed systematically. [Research in Gerontological Nursing, 16(6), 302-311.].

Nurse staffing, quality of care, and quality of life in US nursing homes, 1996­2011: an integrative review.

The purpose of this study was to complete an integrated literature review of the relationship between staffing and quality outcomes in nursing homes. The majority of the reviewed studies showed better outcomes with higher nursing staff but depended heavily on cross-sectional observational studies and failed to differentiate RNs from other nursing staff. A total of 28 articles relating nurse staffing and quality outcomes were systematically reviewed and synthesized. However, each study examined different aspects of staffing and different resident or organizational outcomes, making determination of appropriate staffing levels difficult. The reviewed studies have not clearly defined the relationship between differing levels of nurse-staffing skill mix and specific structure, process, outcome, and composite indicators of quality. The inconsistent findings suggest that further research is needed in this area.

A Methodological Quality Evaluation of Meta-Analyses on Nursing Home Research: Overview and Suggestions for Future Directions.

(1) Background: The nursing home (NH) research field lacks quality reporting about meta-analyses (MAs), and most gradings of MA evidence are biased on analyzing the effectiveness of independent variables in randomized control trials. (2) Objectives: This study aimed to perform a critical methodological review of MAs in the NH research field. (3) Methods: We searched the articles from four databases (PubMed, MEDLINE, CINAHL, and PsycINFO) until 15th January 2021. We reviewed a total of 41 published review articles in the NH research field. (4) Results: The studies primarily fell into the following categories: medicine (17/41), nursing (7/41), and psychiatry or psychology (6/41); 36.6% of the reviewed studies did not use any validated MA guidelines. The lowest correctly reported PRISMA 2000 guideline item was protocol and registration (14.6%), and more than 50% of articles did not report risk of bias. Moreover, 78.0% of studies did not describe missing reports of effect size formula. (5) Discussion: NH researchers must follow appropriate and updated guidelines for their MAs in order to provide validated reviews, as well as consider statistical issues such as the complexity of interventions, proper grouping, and scientific effect-size calculations to improve the quality of their study. Future quality review studies should investigate more diverse studies.

Meal-Monitoring Systems Using Weight and Temperature Sensors for Elder Residents in Long-Term Care Facilities.

This paper presents a few meal-monitoring systems for elder residents (especially patients) in LTCFs by using electronic weight and temperature sensors. These monitoring systems enable to convey the information of the amount of meal taken by the patients in real-time via wireless communication networks onto the mobile phones of their nurses in charge or families. Thereby, the nurses can easily spot the most patients who need immediate assistance, while the families can have relief in seeing the crucial information for the well-being of their parents at least three times a day. Meanwhile, the patients tend to suffer burns of their tongues because they can hardly recognize the temperature of hot meals served. This situation can be avoided by utilizing the meal temperature-monitoring system, which displays an alarm to the patients when the meal temperature is above the reference. These meal-monitoring systems can be easily implemented by utilizing low-cost sensor chips and Arduino NANO boards so that elder-care hospitals and nursing homes can afford to exploit them with no additional cost. Hence, we believe that the proposed monitoring systems would be a potential solution to provide a great help and relief for the professional nurses working in elder-care hospitals and nursing homes.

Factors Influencing the Dementia-Preventive Behaviors among Middle-Aged Persons with Chronic Diseases in Korea.

The purpose of this study was to investigate the influence of dementia literacy, internal health locus of control, and fear of dementia on dementia-preventive behaviors among middle-aged people with chronic diseases. The participants were middle-aged individuals with chronic diseases who had been taking medications for at least three months, recruited using convenience sampling. A total of 123 participants were recruited between 13 and 31 March 2020, using self-reported questionnaires. Data were then analyzed through independent t-test, one-way ANOVA, Pearson's correlation coefficient, and multiple linear regression using the SPSS/WIN 25.0. The results showed that health condition perceived as healthy and dementia literacy were the leading factors influencing dementia-preventive behaviors. These variables showed a 16% explanatory power for dementia-preventive behaviors. Therefore, when the participants' perceived health condition was healthy and the dementia literacy score was higher, the level of dementia-preventive behaviors was also higher. It is necessary to develop educational programs to increase dementia literacy as a major variable in dementia-preventive behaviors, and further research on its efficacy should be conducted. When providing dementia-preventive education programs to middle-aged people who have been exposed to chronic diseases, it is necessary to consider their level of perceived health condition and dementia literacy.

Person-Centered Care Practice, Patient Safety Competence, and Patient Safety Nursing Activities of Nurses Working in Geriatric Hospitals.

Geriatric nursing activities are closely related to patient safety; therefore, nurses' efforts to improve patient safety in geriatric hospitals are important. In the present study, we investigated the relationships between person-centered care practice, patient safety competence, and patient safety during nursing activities in geriatric hospitals. We used the following tools to investigate the factors affecting patient safety during nursing activities: (a) the Korean version of the Person-Centered Care Assessment Tool (P-CAT), (b) the Patient Safety Competence Assessment Tool for Nurses, and (c) the Patient Safety Nursing Activities Assessment Tool for geriatric nurses. The questionnaire survey was completed by 186 geriatric nurses in 12 geriatric hospitals from 1 August to 31 August 2018. We analyzed the survey data using a t-test, one-way ANOVA, Pearson's correlation coefficient, and multiple regression. We identified patient safety skills (ß = 0.417, p < 0.001) and age (ß = 0.209, p = 0.035) as key factors that influence patient safety during nursing activities. Therefore, to improve the quality of patient safety during nursing activities conducted by geriatric nurses, it is necessary to develop strategies to improve patient safety skills and expand the pool of competent nurses with clinical experience.

An Analysis of the Effects of Psychosocial Work Environment on the Retention Intentions of Primary Care Coordinators Nursing Patients with Chronic Illness.

This study aimed to investigate the effects of psychosocial work environment on the retention intentions of care coordinators taking care of patients with chronic illness. A descriptive survey study was conducted with a convenience sample of care coordinators who organized patients and treatment teams that offered professional and persistent treatment. A total of 132 participants were recruited from 19 October to 19 November 2020. The data were analyzed through descriptive statistics, t-tests, ANOVA, Scheffé post hoc, and hierarchical multiple regression using SPSS 26.0. The results showed that work organization and job content (ß = 0.254, p = 0.014) and value at the workplace (ß = 0.245, p = 0.034) had significant effects on the retention intentions of participants. The final model of the study explained 40.1% of participants' retention intentions (F = 11.830, p < 0.001). The development of educational programs and implementation of policies for improving the psychosocial work environment were found to be essential for increasing the retention intentions of professional care coordinators.

Identifying Frequently Used NANDA-I Nursing Diagnoses, NOC Outcomes, NIC Interventions, and NNN Linkages for Nursing Home Residents in Korea.

This study aimed to identify the terminologies of NANDA-I, NOC, NIC, and NNN linkages that have been used for nursing home (NH) residents. This study used a retrospective descriptive design. Data accrued from 57 registered nurses (RNs) in 25 Korean NHs. The RNs randomly selected one resident and assessed for applied NANDA-I, NOC, and NIC from the previous 7 days by reviewing nursing charts and records. Finally, the data of 57 residents in 25 NHs were collected. Results: We identified seven NNN linkages: risk for falls-fall prevention behavior-fall prevention; self-care deficit: bathing/hygiene-self-care: activities of daily living (ADL)-self-care assistance: bathing/hygiene; impaired memory-memory-cognitive stimulation; chronic confusion-neurological status: consciousness-medication management; chronic confusion-memory-medication management; impaired walking-mobility-exercise promotion: strength training; and impaired walking-ambulation-exercise promotion: strength training. The identified core NANDA-I, NOC, NIC, and NNN linkages for NH residents from this study provide a scope of practice of RNs working in NHs.

Increasing Registered Nurse Hours Per Resident Day for Improved Nursing Home Residents' Outcomes Using a Longitudinal Study.

The purpose of this study was to estimate how much resident outcomes can improve with an increase in hours per resident day (HPRD) of registered nurses (RNs) staffing. Nursing home (NH) staff in Korea have serious problems with inappropriate nurse staffing standards and poor working conditions, which lead to poor quality of care for NH residents. This study used a longitudinal survey design. A quota sampling was used with a total of several repeated survey measurement from 2017 to 2020 (n = 74). The independent variable was the amount of nurse staffing HPRD and the outcome variable was the compiled outcome of 15 quality-of-care indicators. Data were directly collected from all participating NHs. A longitudinal, multilevel model was used for analysis. An increase of one unit of RN HPRD (60 min) corresponded to a decrease of about 10.5% of residents with deteriorated quality of care outcomes. This study emphasized that increasing RN HPRD decreased residents' deteriorated outcomes in NHs. This suggests that professional RNs must be secured to an appropriate level to improve the quality of care for NH residents.

Identifying the Risk Factors Associated with Nursing Home Residents' Pressure Ulcers Using Machine Learning Methods.

BACKGROUND: Machine learning (ML) can keep improving predictions and generating automated knowledge via data-driven predictors or decisions. OBJECTIVE: The purpose of this study was to compare different ML methods including random forest, logistics regression, linear support vector machine (SVM), polynomial SVM, radial SVM, and sigmoid SVM in terms of their accuracy, sensitivity, specificity, negative predictor values, and positive predictive values by validating real datasets to predict factors for pressure ulcers (PUs). METHODS: We applied representative ML algorithms (random forest, logistic regression, linear SVM, polynomial SVM, radial SVM, and sigmoid SVM) to develop a prediction model (N = 60). RESULTS: The random forest model showed the greatest accuracy (0.814), followed by logistic regression (0.782), polynomial SVM (0.779), radial SVM (0.770), linear SVM (0.767), and sigmoid SVM (0.674). CONCLUSIONS: The random forest model showed the greatest accuracy for predicting PUs in nursing homes (NHs). Diverse factors that predict PUs in NHs including NH characteristics and residents' characteristics were identified according to diverse ML methods. These factors should be considered to decrease PUs in NH residents.