Leadership and Staff Perceptions on Long-term Care Staffing Challenges Related to Certified Nursing Assistant Retention.

OBJECTIVE: This study investigates practices that may help retain certified nursing assistants (CNAs) and address the staffing challenges faced in long-term care. BACKGROUND: CNAs are critical to quality care and retention has never been more challenging. To solve this staffing crisis, understanding the unique perspective of CNAs is imperative. METHODS: In semistructured interviews, 5 nursing assistants, the director of nursing, and the nursing home administrator at 59 long-term care facilities answered 4 questions, providing multiple perspectives about causes and solutions to CNA staffing challenges. RESULTS: Key responses for each stakeholder group were identified. CNAs highlighted the nature of the job as a bigger challenge than leadership recognized. Although pay is a top concern, emotional support, training, relationship-building, communication, and the work culture can be equally important in reducing turnover. CONCLUSION: When organizational leaders understand how to meet the needs and interests of CNAs, they can reduce turnover.

Acceptability of Using a Robotic Nursing Assistant in Health Care Environments: Experimental Pilot Study.

BACKGROUND: According to the US Bureau of Labor Statistics, nurses will be the largest labor pool in the United States by 2022, and more than 1.1 million nursing positions have to be filled by then in order to avoid a nursing shortage. In addition, the incidence rate of musculoskeletal disorders in nurses is above average in comparison with other occupations. Robot-assisted health care has the potential to alleviate the nursing shortage by automating mundane and routine nursing tasks. Furthermore, robots in health care environments may assist with safe patient mobility and handling and may thereby reduce the likelihood of musculoskeletal disorders. OBJECTIVE: This pilot study investigates the perceived ease of use and perceived usefulness (acceptability) of a customized service robot as determined by nursing students (as proxies for nursing staff in health care environments). This service robot, referred to as the Adaptive Robotic Nurse Assistant (ARNA), was developed to enhance the productivity of nurses through cooperation during physical tasks (eg, patient walking, item fetching, object delivery) as well as nonphysical tasks (eg, patient observation and feedback). This pilot study evaluated the acceptability of ARNA to provide ambulatory assistance to patients. METHODS: We conducted a trial with 24 participants to collect data and address the following research question: Is the use of ARNA as an ambulatory assistive device for patients acceptable to nurses? The experiments were conducted in a simulated hospital environment. Nursing students (as proxies for nursing staff) were grouped in dyads, with one participant serving as a nurse and the other acting as a patient. Two questionnaires were developed and administrated to the participants based on the Technology Acceptance Model with respect to the two subscales of perceived usefulness and perceived ease of use metrics. In order to evaluate the internal consistency/reliability of the questionnaires, we calculated Cronbach alpha coefficients. Furthermore, statistical analyses were conducted to evaluate the relation of each variable in the questionnaires with the overall perceived usefulness and perceived ease of use metrics. RESULTS: Both Cronbach alpha values were acceptably high (.93 and .82 for perceived usefulness and perceived ease of use questionnaires, respectively), indicating high internal consistency of the questionnaires. The correlation between the variables and the overall perceived usefulness and perceived ease of use metrics was moderate. The average perceived usefulness and perceived ease of use metrics among the participants were 4.13 and 5.42, respectively, out of possible score of 7, indicating a higher-than-average acceptability of this service robot. CONCLUSIONS: The results served to identify factors that could affect nurses' acceptance of ARNA and aspects needing improvement (eg, flexibility, ease of operation, and autonomy level).

The development of the new assistant practitioner role in the English National Health Service: a critical realist perspective.

Adopting a critical realist perspective, this article examines the emergence of a relatively new non-professional healthcare role, the assistant practitioner (AP). The role is presented as a malleable construct cascading through and sensitive to structure-agency interaction at different levels of NHS England: the sector, organisation and department. At the core of the analysis is the permissiveness of structures established at the respective levels of the NHS, facilitating or restricting agency as the role progresses through the healthcare system. A permissive regulatory framework at the sector level is reflected in the different choices made by two case study NHS acute hospital trusts, in their engagement with the AP role. These different choices have consequences for how the AP impacts at the departmental level.

The role of collective labor contracts and individual characteristics on job satisfaction in Tuscan nursing homes.

BACKGROUND: The role played by remuneration strategies in motivating health care professionals is one of the most studied factors. Some studies of nursing home (NH) services, while considering wages and labor market characteristics, do not explicitly account for the influence of the contract itself. PURPOSE: This study investigates the relationship between the labor contracts applied in 62 Tuscan NHs and NH aides' job satisfaction with two aims: to investigate the impact of European contracts on employee satisfaction in health care services and to determine possible limitations of research not incorporating these contracts. METHODOLOGY: We apply a multilevel model to data gathered from a staff survey administered in 2014 to all employees of 62 NHs to analyze two levels: individual and NH. Labor contracts were introduced into the model as a variable of NH. RESULTS: Findings show that the factors influencing nursing aides' satisfaction occur at both the individual and NH levels. Organizational characteristics explain 16% of the variation. For individual characteristics, foreign and temporary workers emerge as more satisfied than others. For NH variables, results indicate that the labor contract with the worst conditions is not associated with lower workers' satisfaction. CONCLUSION: Although working conditions play a relevant role in the job satisfaction of aides, labor contracts do not seem to affect it. Interestingly, aides of the NHs with the contract having the best conditions register a significantly lower level of satisfaction compared to the NHs with the worst contract conditions. This suggests that organizational factors such as culture, team work, and other characteristics, which were not explicitly considered in this study, may be more powerful sources of worker satisfaction than labor contracts. PRACTICE IMPLICATIONS: Our analysis has value as a management tool to consider alternative sources as well as the labor contract for employee incentives.

Recognition and assessment of resident' deterioration in the nursing home setting: A critical ethnography.

AIMS AND OBJECTIVES: To explore the recognition and assessment of resident deterioration in the nursing home setting. BACKGROUND: There is a dearth of research exploring how nurses and personal-care-assistants manage a deteriorating nursing home resident. DESIGN: Critical ethnography. METHODS: Observation and semi-structured interviews with 66 participants (general medical practitioners, nurses, personal-care-assistants, residents and family members) in two Australian nursing homes. The study has been reported in accordance with the Consolidated Criteria for Reporting Qualitative Research guidelines. RESULTS: The value of nursing assessment is poorly recognised in the nursing home setting. A lack of clarity regarding the importance of nursing assessments associated with resident care has contributed to a decreasing presence of registered nurses and an increasing reliance on personal-care-assistants who had inadequate skills and knowledge to recognise signs of deterioration. Registered nurses experienced limited organisational support for autonomous decision-making and were often expected to undertake protocol-driven decisions that contributed to potentially avoidable hospital transfers. CONCLUSIONS: Nurses need to demonstrate the importance of assessment, in association with day-to-day resident care and demand standardised, regulated, educational preparation of an appropriate workforce who are competent in undertaking this role. Workforce structures that enhance familiarity between nursing home staff and residents could result in improved resident outcomes. The value of nursing assessment, in guiding decisions at the point of resident deterioration, warrants further consideration.

Classification of patients and nursing staff's sizing: contributions of a management technology. / Classificação de pacientes e dimensionamento de profissionais de enfermagem: contribuições de uma tecnologia de gestão.

OBJECTIVE: Applying PRAXIS® technology resources for patient classification and nursing professional sizing in university hospital inpatient unit. METHOD: Convergent Care Research following the design and instrumentation phases - defined the research theme and purpose, performed in a medical clinic hospital unit involving 633 participants; scrutiny - classification of patients during 30 days of June 2016, followed by sizing, analysis and interpretation of the results - elaborated with the support of the management theorization in hospital nursing. RESULTS: Amongst the total of 633 classifications made, 29.38% were patients in minimal care, 35.71% were intermediate care patients, 33.02% were highly dependent, 1.42% were semi-intensive and 0.47% were in intensive care. Two references were used to carry out the sizing; in both the available team showed to be in deficit. CONCLUSION: The classification of patients and the sizing of nursing professionals are directly related, they are indispensable for management in nursing and difficult to perform daily. Computerized technologies are useful for performing these activities.

Redesigning the Patient Observer Model to Achieve Increased Efficiency and Staff Engagement on a Surgical Trauma Inpatient Unit.

BACKGROUND: Provision of safe and efficient observer care to inpatients whose behavior puts them at risk for injury is a clinically challenging and costly endeavor for hospitals. At Massachusetts General Hospital (MGH; Boston), process improvement strategies were deployed to provide staff with an improved clinical model for patient observation, unit-based responsibility for allocating resources, and strategies to maintain a safer environment. METHODS: In a surgical trauma unit at MGH, a team of nursing leaders and clinicians created an innovative process to identify, assess, and develop best practices for ensuring patient safety in the hospital environment. Patients with delirium were identified as the most prevalent and concerning patient group, and specific interventions were developed to address their unique needs. From December 2012 through June 2014, the team successfully piloted the best practices (July 16, 2013-September 30, 2013) and implemented them. RESULTS: The baseline outcome metric of patient observer direct-care hours decreased from a median of 208 hours/week (January 1, 2012-July 13, 2013) to a median of 112 hours/week (July 14, 2013-June 28, 2014); a 46% decrease in utilization. Fall rate (falls per 1,000 patient-days) remained unchanged postimplementation, and staff satisfaction with the patient observer model increased from 9% to 72%, while costs associated with providing observer care remained stable. CONCLUSIONS: Providing the inpatient unit staff with the knowledge and tools needed to optimally manage patients with at-risk behaviors, including delirium, significantly decreased the number of staff hours spent at the bedside providing observation, did not negatively affect the unit fall rate, and increased staff engagement at no additional expense to the unit.

The nursing associate role: have we been here before?

What should the nursing workforce of the future look like? It is a question all nurse leaders should ask themselves.

Strategies used by nurses to promote teamwork in an emergency room. / Estratégias utilizadas pelos enfermeiros para promover o trabalho em equipe em um serviço de emergência.

Objective to analyze the strategies used by nurses to promote teamwork in a hospital emergency room. Method qualitative case study research with 20 nurses in the emergency unit of a university hospital in southern Brazil. Data were collected between June and September 2009 through participant observation and semi-structured interviews, and analyzed using thematic analysis. Results the strategies used by the nurses to promote teamwork in the emergency unit were articulating professional actions; establishing relationships of cooperation; building and maintaining friendly ties; and managing conflict. Conclusion nurses notably make the connections between the practices of the health teams and mediate the relationships established between health professionals to improve care practices.

Social class and mental health: testing exploitation as a relational determinant of depression.

This study tests whether social class exploitation operates as a relational mechanism that generates mental health inequalities in the nursing home industry. We ask, does social class exploitation (i.e., the acquisition of economic benefits from the labor of those who are dominated) have a systematic and predictable impact on depression among nursing assistants? Using cross-sectional data from 868 nursing assistants employed in 50 nursing homes in three U.S. states, we measure social class exploitation as "ownership type" (private for-profit, private not-for-profit, and public) and "managerial domination" (labor relations violations, perceptions of labor-management conflict). Depression is assessed using the original and revised versions of the Center for Epidemiologic Studies Depression Scale (CES-D and CESD-R). Using two-level logistic regressions, we find that private for-profit ownership and higher managerial domination are predictive of depression among nursing assistants even after adjustment for potential confounders and mediators. Our findings confirm the theoretical and empirical value of applying a social class approach to understanding how mental health inequalities are generated through exploitative mechanisms. Ownership type and managerial domination appear to affect depression through social relations that generate mental health inequalities through the process of acquiring profits, controlling production, supervising and monitoring labor, and enforcing disciplinary sanctions.

Clinical Partners' Perceptions of Patient Assignments According to Acuity.

Clinical partners (CPs) experienced disproportionate workloads related to patients' levels of acuity. This problem was addressed on a medical-surgical unit by developing patient acuity ratings and equitable acuity assignments for the CPs.

Exploring the activity profile of health care assistants and nurses in home nursing.

Are home nurses (also known as community nurses) ready for their changing role in primary care? A quantitative study was performed in home nursing in Flanders, Belgium, to explore the activity profile of home nurses and health care assistants, using the 24-hour recall instrument for home nursing. Seven dates were determined, covering each day of the week and the weekend, on which data collection would take place. All the home nurses and health care assistants from the participating organisations across Flanders were invited to participate in the study. All data were measured at nominal level. A total of 2478 home nurses and 277 health care assistants registered 336 128 (47 977 patients) and 36 905 (4558 patients) activities, respectively. Home nurses and health care assistants mainly perform 'self-care facilitation' activities in combination with 'psychosocial care' activities. Health care assistants also support home nurses in the 'selfcare facilitation' of patients who do not have a specific nursing indication.

Benefit of using volunteers for mealtime assistance.

BACKGROUND: Poor nutrition is common among older inpatients and giving them enough help to eat and drink is challenging for time-pressured nurses. AIM: To compare the use of trained volunteer mealtime assistants (MTAs) with usual care on female medicine for older people wards. METHOD: A total of 29 MTAs helped 3,911 patients on the intervention ward on 229 weekday lunchtimes. RESULTS: Interviews and focus groups with patients, relatives, nurses and volunteers confirmed that MTAs improved the quality of mealtime care. Staff and MTAs recognised they were able to give extra time to patients who struggled to eat, which relieved pressure on nursing staff. CONCLUSION: Trained volunteers can help older female patients at mealtimes, including helping them to eat, in a manner that is safe, sustainable and well received.

[The nurse-healthcare assistant partnership: a learning tool?]. / Le binôme infirmière/aide-soignante: un outil d'apprentissage?

In intensive care, working in a nurse-healthcare assistant partnership is essential. It facilitates the way they receive the patient, organise and work together in performing technical procedures, provide personal care and comfort and compensate for a decrease in or loss of autonomy.

[Involvement of healthcare assistants in nursing procedures]. / La collaboration de l'aide-soignante aux actes de l'infirmière.

Healthcare assistants are authorised to perform nursing procedures in accordance with regulated conditions. They do not perform their functions autonomously but carry out their actions within the framework of the nurse's responsibilities.

[A partnership for the benefit of patients in geriatrics]. / Un tandem au service des patients en gériatrie.

In geriatrics, with the longer life expectancy and the growing number of neurodegenerative diseases, the need for care is increasing and working together is fundamental. The nurse/healthcare assistant partnership is the guarantor of improving patients' quality of care.

[The role of care assistants at the end of life]. / Place des auxiliaires de vie auprès de patients en fin de vie.

Personal care assistants have a special place, at home, with patients at the end of their life. At the interface between carers, relatives and the person they take care of, they often live intense situations, in close contact. The Parisian palliative care network Quiétude shares their voice.

[The nurse-healthcare assistant partnership in a mobile pain and palliative care team]. / Le duo infirmière/aide-soignante en équipe mobile douleur et soins palliatifs.

The mission of the mobile pain and palliative care team is to improve the quality of care and comfort of patients. At Longjumeau general hospital the nurse-healthcare assistant partnership within this team enables the patient to benefit from the caregivers' two-way perspective, while allowing the professionals to share knowledge and to be stronger in the face of suffering.

More than a checklist: a realist evaluation of supervision of mid-level health workers in rural Guatemala.

BACKGROUND: Mid-level health workers (MLHWs) form the front-line of service delivery in many low- and middle-income countries. Supervision is a critical institutional intervention linking their work to the health system, and it consists of activities intended to support health workers' motivation and enable them to perform. However its impact depends not only on the frequency of these activities but also how they are carried out and received. This study aims to deepen understanding of the mechanisms through which supervision activities support the performance of auxiliary nurses, a cadre of MLHWs, in rural Guatemala. METHODS: A multiple case study was conducted to examine the operation of supervision of five health posts using a realist evaluation approach. A program theory was formulated describing local understanding of how supervision activities are intended to work. Data was collected through interviews and document review to test the theory. Analysis focused on comparison of activities, outcomes, mechanisms and the influence of context across cases, leading to revision of the program theory. RESULTS: The supervisor's orientation was identified as the main mechanism contributing to variation observed in activities and their outcomes. Managerial control was the dominant orientation, reflecting the influence of standardized performance criteria and institutional culture. Humanized support was present in one case where the auxiliary nurse was motivated by the sense that the full scope of her work was valued. This orientation reflected the supervisor's integration of her professional identity as a nurse. CONCLUSIONS: The nature of the support health workers received was shaped by supervisors' orientation, and in this study, nursing principles were central to humanized support. Efforts to strengthen the support that supervision provides to MLHWs should promote professional ethos as a means of developing shared performance goals and orient supervisors to a more holistic view of the health worker and their work.

Staffing and job satisfaction: nurses and nursing assistants.

AIM: The aim of this study was to examine the relationship between staffing and job satisfaction of registered nurses (RNs) and nursing assistants (NAs). BACKGROUND: Although a number of previous studies have demonstrated the link between the numbers of patients cared for on the last shift and/or perceptions of staffing adequacy, we could find only one study that utilized a measure of actual staffing (opposed to perceptions of staffing adequacy) and correlated it with job satisfaction of registered nurses. METHODS: This cross-sectional study included 3523 RNs and 1012 NAs in 131 patient care units. Staff were surveyed to determine job satisfaction and demographic variables. In addition, actual staffing data were collected from each of the study units. RESULTS: Hours per patient day was a significant positive predictor for registered nurse job satisfaction after controlling for covariates. For NAs, a lower skill mix was marginally significant with higher job satisfaction. In addition, the more work experience the NAs reported, the lower their job satisfaction. CONCLUSION: Adequate staffing levels are essential for RN job satisfaction whereas NA job satisfaction depends on the number of assistive personnel in the mix of nursing staff. IMPLICATIONS FOR NURSING MANAGEMENT: Two implications are (1) providing adequate staffing is critical to maintain RN job satisfaction and (2) the NA job needs to be re-engineered to make it a more attractive and satisfying career.