Job demands and job strain as risk factors for employee wellbeing in elderly care: an instrumental-variables analysis.

BACKGROUND: The association between psychosocial work environment and employee wellbeing has repeatedly been shown. However, as environmental evaluations have typically been self-reported, the observed associations may be attributable to reporting bias. METHODS: Applying instrumental-variable regression, we used staffing level (the ratio of staff to residents) as an unconfounded instrument for self-reported job demands and job strain to predict various indicators of wellbeing (perceived stress, psychological distress and sleeping problems) among 1525 registered nurses, practical nurses and nursing assistants working in elderly care wards. RESULTS: In ordinary regression, higher self-reported job demands and job strain were associated with increased risk of perceived stress, psychological distress and sleeping problems. The effect estimates for the associations of these psychosocial factors with perceived stress and psychological distress were greater, but less precisely estimated, in an instrumental-variables analysis which took into account only the variation in self-reported job demands and job strain that was explained by staffing level. No association between psychosocial factors and sleeping problems was observed with the instrumental-variable analysis. CONCLUSIONS: These results support a causal interpretation of high self-reported job demands and job strain being risk factors for employee wellbeing.

Ownership type and team climate in elderly care facilities: the moderating effect of stress factors.

AIMS: This paper is a report of a study examining the association between ownership type and perceived team climate among older people care staff. In addition, we examined whether work stress factors (time pressure, resident-related stress, role conflicts and role ambiguity) mediated or moderated the above mentioned association. BACKGROUND: There has been a trend towards contracting out in older people care facilities in Finland and the number of private for-profit firms has increased. Studies suggest that there may be differences in employee well-being and quality of care according to the ownership type of older people care. METHODS: Cross-sectional survey data was collected during the autumn of 2007 from 1084 Finnish female older people care staff aged 18-69 years were used. Team Climate Inventory was used to measure team climate. Ownership type was divided into four categories: for-profit sheltered homes, not-for-profit sheltered homes, public sheltered homes and not-for-profit nursing homes. Analyses of covariance were used to examine the associations. RESULTS: Team climate dimensions participative safety, vision and support for innovation were higher in not-for-profit organizations (both sheltered homes and nursing homes) compared to for-profit sheltered homes and public sheltered homes. Stress factors did not account for these associations but acted as moderators in a way that in terms of task orientation and participative safety employees working in for-profit organizations seemed to be slightly more sensitive to work-related stress than others. CONCLUSION: Our results suggest that for-profit organizations and public organizations may have difficulties in maintaining their team climate. In consequence, these organizations should focus more effort on improving their team climate.

Quality of care plans in long-term care facilities for the older persons-How well is information from RAI assessments utilised in care planning?

BACKGROUND: In Finland, care plans at long-term care facilities (LTCF) for the older persons should be based on information from Resident Assessment Instrument (RAI) assessments and the principles of structured data. Hence, managers are responsible for ensuring that the RAI system is used to a satisfactory extent, the provided information is used in care planning, and that staff members are competent at composing high-quality care plans. AIM: To explore the congruence between first-line managers' assessments of the extent to which care plans include RAI information and separately observed RAI-related contents of care plans. METHODS: The study was based on a descriptive, cross-sectional survey of first-line managers (n = 15) from three LTCF organisations and a randomly selected sample of care plans (n = 45) from two LTCF organisations in Finland. Manager responses and analysis of care plans were reviewed at a general level. The data were gathered in 2019 and analysed using statistical methods and content analysis. RESULTS: First-line managers' assessments of the extent to which their units' care plans included RAI information did not match the observed care plan contents. The care plan analysis revealed that managers significantly overestimated the extent to which care plans included RAI-related content. CONCLUSION: Managers at LTCF organisations need more training to be able to sufficiently support their staff in using RAI information to draft high-quality care plans. IMPLICATION FOR PRACTICE: Care plans must include a higher level of information related to RAI assessments. To develop competencies in drafting high-quality care plans, training related to RAI information utilisation on all aspects of the care plan should be emphasised and training should be provided to first-line managers and more broadly across the nursing staff.

Managers' Perspectives of Quality of Care in Service Housing and Home Care Services: A Qualitative Study.

The aim of this study was to illuminate facilitators and barriers to the quality of care in service housing and home care services, as described by managers. In total, 17 service housing and home care service front-line managers participated in this study. The interviews were conducted in Finland during October 2021 using semi-structured interviews. Qualitative content analysis was used to analyze the data. Described facilitators to the quality of care included: staff dedication and motivation, a positive psycho-social working environment, sufficient staffing, coaching management, and optimized tasks. Described barriers included: increased efficiency demands, staffing challenges, inefficient division of labor, conflicts within the working community, and disruptions due to COVID-19. The results suggest that recruiting and retaining sufficient dedicated and motivated staff is paramount to ensuring quality of care from the managerial perspective, and it seems changes in the working culture may support quality of care in a cost-efficient way.

Method for Assigning Priority Levels in Acute Care (MAPLe-AC) predicts outcomes of acute hospital care of older persons--a cross-national validation.

BACKGROUND: Although numerous risk factors for adverse outcomes for older persons after an acute hospital stay have been : identified, a decision making tool combining all available information in a clinically meaningful way would be helpful for daily hospital practice. The purpose of this study was to evaluate the ability of the Method for Assigning Priority Levels for Acute Care (MAPLe-AC) to predict adverse outcomes in acute care for older people and to assess its usability as a decision making tool for discharge planning. METHODS: Data from a prospective multicenter study in five Nordic acute care hospitals with information from admission to a one year follow-up of older acute care patients were compared with a prospective study of acute care patients from admission to discharge in eight hospitals in Canada. The interRAI Acute Care assessment instrument (v1.1) was used for data collection. Data were collected during the first 24 hours in hospital, including pre-morbid and admission information, and at day 7 or at discharge, whichever came first. Based on this information a crosswalk was developed from the original MAPLe algorithm for home care settings to acute care (MAPLe-AC). The sample included persons 75 years or older who were admitted to acute internal medical services in one hospital in each of the five Nordic countries (n = 763) or to acute hospital care either internal medical or combined medical-surgical services in eight hospitals in Ontario, Canada (n = 393). The outcome measures considered were discharge to home, discharge to institution or death. Outcomes in a 1-year follow-up in the Nordic hospitals were: living at home, living in an institution or death, and survival. Logistic regression with ROC curves and Cox regression analyses were used in the analyses. RESULTS: Low and mild priority levels of MAPLe-AC predicted discharge home and high and very high priority levels predicted adverse outcome at discharge both in the Nordic and Canadian data sets, and one-year outcomes in the Nordic data set. The predictive accuracy (AUC's) of MAPLe-AC's was higher for discharge outcome than one year outcome, and for discharge home in Canadian hospitals but for adverse outcome in Nordic hospitals. High and very high priority levels in MAPLe-AC were also predictive of days to death adjusted for diagnoses in survival models. CONCLUSION: MAPLe-AC is a valid algorithm based on risk factors that predict outcomes of acute hospital care. It could be a helpful tool for early discharge planning although further testing for active use in clinical practice is still needed.

Vision and hearing impairments and their associations with falling and loss of instrumental activities in daily living in acute hospitalized older persons in five Nordic hospitals.

BACKGROUND: Many older people believe sensory problems are inevitably, a part of growing old, and avoid assessment and help. Such problems are often also overlooked by health professionals. The aim of this study was to find the prevalence of hearing and vision impairment and their associations with loss of instrumental activities in daily living (IADL) and risk of falling in patients aged 75 years or older, admitted to a medical ward in an acute hospital in each of the five Nordic countries. METHOD: The Minimum Data Set for Acute Care was used for data collection in 770 patients. Premorbid data, admission data and history of falls over 3 months were obtained on admission by interview and observation. Hearing impairment was present if the patient required a quiet setting to be able to hear normal speech. Vision impairment was defined as unable to read regular print in a newspaper. RESULTS: Bivariate and logistic regression analyses were performed. Forty-eight per cent of the patients had a hearing impairment, 32.3% had vision impairment and 20.1% had both. Hearing impairment was associated with falling but not in the logistic regression model. Hearing and vision impairment were associated with loss of IADL but only combined impairment was independently. CONCLUSION: Hearing and vision impairments were frequent among older patients in the medical wards. Falling was associated with hearing loss and IADL loss with hearing, vision and combined impairments. Sensory loss was also associated with fear of falling. It is recommended routinely to screen sensory functions in older patients in a medical setting. Intervention studies are needed to determine whether improvements in hearing and vision can prevent falls and further loss of function in this patient population.

Use of antipsychotics in older home care patients in Finland.

OBJECTIVE: To investigate the use of antipsychotic medications, and factors associated with such use, in elderly patients in home care in Finland. METHOD: A retrospective study was designed using cross-sectional data gathered between 1 July and 31 December 2004 in Finland. Data were extracted from the Resident Assessment Instrument (RAI) database, based on Minimum Data Set for Home Care (MDS-HC) assessments. Patients aged >or=65 years from five home care units in different parts of Finland (urban and rural) were included, yielding a total of 1106 patient assessments. RESULTS: The prevalence of antipsychotic use was 11% among home care patients. Factors independently associated with use of antipsychotics in the logistic regression model were: any psychiatric diagnosis (odds ratio [OR] 6.62, 95% CI 4.19, 10.45), delusions (OR 4.19, 95% CI 2.22, 7.90), parkinsonism (OR 3.08, 95% CI 1.07, 8.87), not at ease interacting with others (OR 1.88, 95% CI 1.06, 3.36) and moderate-to-severe cognitive impairment (OR 1.47, 95% CI 1.06, 2.04). By contrast, patients aged >or=85 years (OR 0.59, 95% CI 0.43, 0.81) were significantly less likely to be taking antipsychotics. Use of atypical antipsychotic medication was associated in the logistic regression model with delusions (OR 4.05, 95% CI 2.01, 8.17), parkinsonism (OR 3.66, 95% CI 1.10, 12.19), any psychiatric diagnosis (OR 3.06, 95% CI 1.66, 5.63), moderate-to-severe cognitive impairment (OR 2.0, 95% CI 1.32, 3.03) and age >or=85 years (OR 0.66, 95% CI 0.44, 0.99). However, use of conventional antipsychotics was associated only with any psychiatric diagnosis (OR 8.88, 95% CI 5.05, 15.61) and age >or=85 years (OR 0.65, 95% CI 0.44, 0.98). CONCLUSION: The prevalence of antipsychotic medication use in elderly home care patients was higher than that previously reported among elderly people living in the community in Finland and Sweden (3-9%). Several predictive factors such as psychiatric diagnosis, delusions and cognitive impairment were associated with use of antipsychotics whereas there was a negative association between age >or=85 years and use of antipsychotics.

Drug use and pressure ulcers in long-term care units: do nurse time pressure and unfair management increase the prevalence?

AIMS: This study examined the associations between nurse working conditions (time pressure and perceived unfair management) and quality indicators (prevalence of antianxiety or hypnotic drug use and pressure ulcers) in long-term care units. BACKGROUND: Differences persist across long-term care facilities in their care processes and resident outcomes even after adjusting for residents' clinical conditions. Little is known about how nurses' working conditions influence the quality of care. DESIGN: Survey. METHODS: Data on working conditions were drawn in 2002 from 724 nurses in 66 long-term care units that reported quality indicators based on the Resident Assessment Instrument system as measured by Minimum Data Set. Percentage change in the quality indicators from 2002 were estimated using hierarchical multiple regression analyses with adjustments made for the baseline quality indicators (2001) and unit structural factors (unit size and staffing level). RESULTS: Unit time pressure increased the prevalence of both quality problems (p-values <0.05). Perceived unfair management was related to increased drug use (p = 0.038). CONCLUSIONS: The findings of this research suggest that quality of care can be improved by enhancing nurse working conditions. RELEVANCE TO CLINICAL PRACTICE: Organisational initiatives should be aimed at reducing time pressures and promoting fair managerial procedures that engage all nursing staff in the decision-making in long-term care settings.

Comparing psychogeriatric units to ordinary long-term care units - are there differences in case-mix or clinical symptoms?

This study is a comparative analysis of long-term psychogeriatric and mixed-care unit patient characteristics in nursing homes and hospitals in Helsinki. The role of the so-called psychogeriatric nursing homes is still under question and not well developed. The aims of the study were to identify and survey psychogeriatric wards and analyze whether these units differ from the rest of the long-term units/wards in terms of patients' characteristics. Participants studied were a total of 2828 elderly long-term care residents, of which 372 were living in long-term psychogeriatric and 2456 in ordinary long-term care units. Data were drawn from the Resident Assessment Instrument (RAI) database and had been collected in the project "Benchmarking and implementation of RAI in Elderly Care in Finland". Scales and items based on Minimum Data Set were used for the comparisons. Resident groups in psychogeriatric units and in ordinary, mixed-client settings were clearly distinguishable. The psychogeriatric residents were younger, had more comorbidity as to psychiatric diseases, and had more often psychiatric symptoms and psychotropic medications. The residents in psychogeriatric units did not differ in cognitive and functional status from those in mixed-client units and had similar comorbidity as to somatic diseases. This study shows that psychiatric symptoms that need to be addressed are common in long-care facilities. The results emphasize the importance of recognition of the multiple care needs of elderly with severe mental symptoms or illness.

Daily rehabilitation nursing increases the nursing time spent on residents.

Nurses are primary managers of rehabilitation nursing activities. When improving rehabilitation nursing, it is important to understand the content of care provided and time spent on residents. This study discusses the allocation of nursing staff time within a context of rehabilitation nursing. The variables of rehabilitation nursing and residents' characteristics were derived from the Resident Assessment Instrument. The wage-adjusted direct nursing time was obtained from a time measurement study carried out in November 2002 in long-term care facilities in southern Finland. The average direct wage-adjusted nursing time spent on resident was 93.8 min per day. Residents receiving daily rehabilitation nursing were allocated approximately 8 min more wage-adjusted direct nursing time than their peers. More 'hands in care' staff is required for adopting rehabilitation nursing in long-term care units. Maximizing residents' independency should be the goal for rehabilitation care and therefore the focus for allocating both nursing and rehabilitation staff to units and facilities.

Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment.

AIM: To compare nurses' and physicians' documentation of geriatric issues and explore double documentation and undocumented areas of importance in an acute care setting in two Nordic countries. METHOD: 158 participants, aged 75+, of whom the Minimum Data Set for Acute Care (MDS-AC) instrument was conducted at admission and from which 56 variables were taken in comparison with notes from patient records documented by nurses and/or physicians in two acute care hospitals, in Finland and Iceland. FINDINGS: Documentation of the impairment of personal Activities of Daily Living (ADL) was missing in 40-60% of the nurses' reports and 80-97% of the physician's reports. Even poorer was the documentation of the impairment of Instrumental Activities of Daily Living (IADL), of which 75% was not reported by the nurses and 85-96% by the physicians. Cognitive function was recorded in only 30-40% of the cases. CONCLUSIONS: The traditional patient record in acute care setting lacks several variables of functional abilities of the older patients. Nurses took more responsibility in the documentation of functional abilities, compared with physicians, but they could improve. Using a standardized instrument such as the MDS-AC can improve documentation and make a basis for a clearer delineation in responsibilities for documentation between nurses and physicians and thereby improve outcome of care.

Predictors for Unplanned Hospitalization of New Home Care Clients.

OBJECTIVES: To identify factors predicting unplanned hospitalization of new home care clients using the Resident Assessment Instrument for Home Care (RAI-HC). DESIGN: A register-based study based on RAI-HC assessments and nationwide hospital discharge records. SETTING: Municipal home care services in Finland. PARTICIPANTS: New Finnish home care clients aged 63 and older (N = 15,700). MEASUREMENTS: Information from home care clients' first RAI-HC assessment was connected to information regarding their first hospitalization over 1 year of follow-up. Multivariate regression analyses were used to evaluate the independent risk factors for hospitalization. RESULTS: Forty-three percent (n = 6,812) of participants were hospitalized at least once. The strongest independent risk factors were hospitalization during the year preceding the RAI-HC assessment (odds ratio (OR) = 2.01, 95% confidence interval (CI) = 1.87-2.16), aged 90 and older (OR = 1.69, 95% CI = 1.48-1.92), renal insufficiency (OR = 1.44, 95% CI = 1.22-1.69) and using 10 or more drugs (OR = 1.41, 95% CI = 1.26-1.58). Other independent risk factors were male sex, previous emergency department visits or other acute outpatient care use, daily urinary incontinence, fecal incontinence, history of falls, cognitive impairment, chronic skin ulcer, pain, unstable health status, housing-related problems, and poor self-rated health. Parkinson's disease, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and cancer were independent prognostic indicators. A body mass index of 24 kg/m2 or greater and the client's own belief that functional capacity could improve had a protective role. CONCLUSION: Assessing new home care clients using the RAI-HC reveals modifiable risk factors for unplanned hospitalization. Systematic assessment by a multidisciplinary team at the beginning of the service and targeting modifiable risk factors could reduce the risk of unplanned hospitalization.

The moderating effect of employee hostility on the association of long-term elderly care unit's negative resident characteristics to employee stress and well-being.

This study examined the moderating effect of employee hostility on the association of unit-level resident characteristics (depression and behavioral problems) to individual-level employee's resident-related stress and psychological well-being during 1-year follow-up study among 501 employees in elderly care. Our results showed that employee hostility was associated with decreased psychological well-being. In addition, hostility moderated the association between unit-level proportion of depressive residents and resident-related stress experienced by the individual employees. Hostile employees reported increased resident-related stress irrespective of the proportion of depressed residents in the unit. Instead, nonhostile employees were sensitive to the depression in the unit. They reported low levels of stress when depression levels in the unit were low and increased stress when depression levels were high.

Perceived and observed quality of long-term care for residents - Does functional ability account?

BACKGROUND: Measuring quality in long-term residential care involves challenges concerning both the measurement method and the impaired functional ability of many older people. Ensuring quality in care is even more important for people with functional impairments, as this is a vulnerable group who may be unable to report poor quality of care for themselves. AIMS AND OBJECTIVES: The aim of this study was to analyse how perceived and observed assessments of the quality of care varied according to the residents' functional ability. DESIGN: The data (n = 278) used in the analyses included residents', family members' and staff assessments of perceived and observed quality of care combined with the Resident Assessment Instrument (RAI) scales measuring the same residents' functional abilities (physical, psychological, cognitive and social). Observations were included in the data if all four assessment types (by residents, family members, staff and the RAI) were available. The dimensions of quality of care emerging from the factor analysis were used. METHODS: Linear regression was used to explore the association between resident's functional abilities and assessed quality of care. RESULTS: Higher level of depression symptoms and higher level of dependency in activities of daily living (ADL) were significantly associated with lower level of perceived and observed quality of care. By contrast, the level of residents' cognitive functioning was not significantly associated with any quality dimensions. The social aspect was the only dimension of functional ability on which better functional ability indicated better quality of care, although differences between respondent groups were also observed. CONCLUSIONS: These analyses emphasize the importance of taking residents' functional ability into account when collecting information on and interpreting the results of perceived and observed quality of care reported separately by residents, family members and staff. IMPLICATIONS FOR PRACTICE: The information obtained can inform care professionals of how dimensions of residents' functional impairments are associated with perceived and observed quality of care and the quality of older people's care can thereby be improved.

Patient- and ward-level determinants of nursing time in nursing facilities.

OBJECTIVES: To explore the patient- and ward-level determinants of wage-adjusted nursing time in long-term care wards for the elderly with a view to improving efficiency of the use of labour resources. METHODS: The wage-adjusted nursing time given to patients was obtained from a time measurement study. Patient characteristics were based on the Minimum Data Set 2.0 of the Resident Assessment Instrument for nursing homes. Ordinary least-squares regression analysis and multilevel modelling were used to disentangle the effect of patient- and ward-level factors on nursing time. RESULTS: A significant difference in wage-adjusted nursing time between wards was detected, which was partly explained by characteristics of patients in wards. The combination of patients' physical functioning and cognition and the Resource Utilization Groups RUG-III/22 resource use classification explained 20-25% of patients' nursing time over a 24-hour period. Variables related to the operational environment of the ward did not explain differences in wage-adjusted nursing time once the patient profile of the ward had been controlled for. The results also showed notable unmeasured patient and ward level effects, inefficiency and randomness in the allocation of nursing time. CONCLUSIONS: By improving the allocation and use of labour resources, the substantial variation in nursing time between wards could be diminished. Managers should allocate their staff primarily according to patients' resource needs.

Advance orders to limit therapy in 67 long-term care facilities in Finland.

OBJECTIVE: To assess the documentation of a do-not-attempt-resuscitation (DNAR) or do-not-hospitalize (DNH) orders in the medical record and to determine factors related to these orders. MATERIALS AND METHODS: Five thousand six hundred and fifty four subjects from three different levels of institutional long-term care (LTC), chronic care hospitals (n = 1989), nursing homes (n = 3310), and assisted living (n = 335) in 67 LTC facilities in 19 municipalities were assessed. RESULTS: Out of these patients, 751 (13%) had a DNAR order and only 36 (0.6%) had a DNH order. The variation in DNAR orders between individual LTC institutions was enormous, ranging from 0 to 92%. In logistic regression analysis, individual institutions and their local caring cultures had the strongest explanatory value (R(2) = 0.49) for advance orders to limit therapy. Impaired activity in daily living (ADL) function (R(2) = 0.11), impaired cognition (R(2) = 0.07), level of LTC (R(2) = 0.05), and diagnoses (R(2) = 0.04) did not provide adequate explanations. Terminal prognosis was not significantly associated with advance orders. CONCLUSIONS: We found marked differences in the use of DNAR and DNH orders between caring units. Diseases and ADL status were only weakly significant as background factors. Open discussions, general guidelines, and research about the adequacy of DNAR decisions are needed to improve equality and self-empowerment among the elderly residing in institutions.

Assessing prevalence of antimicrobial use and infections using the minimal data set in Finnish long-term care facilities.

Of all residents (n = 12,784) for whom a minimum data set 2.0 form was completed in long-term care facilities (n = 253) using a Resident Assessment Instrument in April and September 2011 in Finland, 16% received antimicrobials, most commonly methenamine (42%) and trimethoprim (24%). The prevalence of urinary tract infections was 8%, wound infection 2%, and pneumonia 2%. Minimum data set form provides a feasible tool for collecting data on antibiotic use and infections in long-term care facilities.

Job demands and musculoskeletal symptoms among female geriatric nurses: the moderating role of psychosocial resources.

The present study examined whether job resources (job control, social support, and distributive justice) moderate the associations of high job demands induced by physical and mental workload with musculoskeletal symptoms among geriatric nurses. The data were drawn in Finland from 975 female nurses working in 152 geriatric units who responded to a survey questionnaire. Information on the objective workload in terms of resident characteristics and structural factors was also collected at the unit level. After adjusting for the objective workload, multilevel logistic regression analyses showed that self-reported physical workload was associated with higher risk of musculoskeletal symptoms (OR = 1.93, 95 % CI [1.38, 2.72]) among nurses with low social support. In addition, mental workload was associated with higher risk of musculoskeletal symptoms (OR = 1.72, 95% CI [1.12, 2.62]) for those with low distributive justice. The results suggest that social support and fair reward systems may help to buffer against the detrimental effects of heavy job demands on nurses' musculoskeletal symptoms.

The association of ownership type with job insecurity and worry about job stability: the moderating effects of fair management, positive leadership, and employment type.

This study examined whether the ownership type is associated with job insecurity and worry about job stability and whether the type of employment contract, positive leadership, and fair management moderated these associations. Survey data from 1249 Finnish female elderly care staff aged 18 to 69 years were used. Job insecurity and worry about job stability were highest in not-for-profit sheltered homes. However, positive leadership and fair management were able to mitigate this insecurity and worry. Job insecurity was highest among fixed-term employees in public sheltered homes or not-for-profit nursing homes. Thus, promoting good leadership and fair management would be of importance.